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Slide 1-

Schizophrenia and Other Psychotic Disorders M2 Psychiatry Sequence Michael Jibson Fall 2008
Slide 2-

Psychosis Significant impairment in reality testing, as evidenced by hallucinations delusions thought disorganization grossly disorganized behavior
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Hallucination False sensory perception Auditory Visual Tactile Olfactory Gustatory
Slide 4-

Delusion False belief that is based on incorrect inference about external reality firmly held despite obvious evidence to the contrary not sanctioned by the individual’s culture or group
Slide 5-

Delusion Persecutory - belief that one is being malevolently treated in some way Referential - neutral occurrences are seen as directed toward oneself Religious - delusional beliefs of a spiritual or religious nature Control - thoughts, feelings, or body feel controlled or manipulated (cont.)
Slide 6-

Delusion (cont.) Grandiose - inflated sense of worth, power, accomplishment, etc. Somatic - belief that one’s body is defective, has been changed, or is diseased Jealous - belief that one’s sexual partner is unfaithful Erotomanic - belief that another (often famous) person is in love with one
Slide 7-

Disorganized Thoughts or Behavior Meaningless or chaotic speech Loose associations Bizarre behavior Poorly directed behavior Catatonia
Slide 8-

Schizophrenia Historical Background Kraepelin - Dementia Praecox (Dementia Praecox and Paraphrenia, 1896)
Slide 9-

Schizophrenia Historical Background Bleuler’s “Four A’s” (Dementia Praecox; or, the Group of Schizophrenias, 1911) Autism Loose associations Affective disturbance Ambivalence
Slide 10-

Schizophrenia Historical Background Schneider’s “First-Rank Symptoms” (1950’s) Audible thoughts More than one voice arguing or discussing the patient Voices commenting on the patient’s activities Thought insertion Thought withdrawal (cont.)
Slide 11-

Schizophrenia Historical Background Schneider’s “First-Rank Symptoms” (1950’s) (cont.) Thought broadcasting Made feelings/Made impulses Made volition Somatic passivity Delusional perception
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Schizophrenia Historical Background DSM-III (1980) a. Active psychosis b. Functional deterioration
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Schizophrenia DSM-IV Diagnostic Criteria A. At least two psychotic symptoms for one month B. Social or occupational dysfunction C. Six month duration of symptoms D. Schizoaffective and major mood disorders have been excluded E. Substance abuse and medical conditions have been excluded F. Not due to a pervasive developmental disorder (e.g. autism)
Slide 14-

Schizophrenia American Psychiatric Association: Diagnostic and Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR)
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Schizophrenia Subtype Definition and Hierarchy Paranoid type Preoccupation with one or more delusions or frequent auditory hallucinations No prominent disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect
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Schizophrenia Subtype Definition and Hierarchy Disorganized type Prominent disorganized speech Disorganized behavior and Flat or inappropriate affect
Slide 17-

Schizophrenia Subtype Definition and Hierarchy Catatonic type Motoric immobility, catalepsy (waxy flexibility) or stupor Excessive, purposeless motor activity Extreme negativism (motiveless resistance to instructions) or mutism (cont.)
Slide 18-

Schizophrenia Subtype Definition and Hierarchy Catatonic type (cont.) Peculiarities of voluntary movement or posture, stereotyped movements, prominent mannerisms, or prominent grimacing Echolalia (echoing words) or echopraxia (mimicking gestures)
Slide 19-

Schizophrenia Subtype Definition and Hierarchy Undifferentiated type None of the above
Slide 20-

Schizophrenia Subtype Definition and Hierarchy Residual type Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior Continuing evidence of disturbance (negative symptoms, attenuated psychotic symptoms, odd beliefs, unusual perceptual experiences)
Slide 21-

Schizophrenia Symptom Descriptions Positive symptoms Delusions Hallucinations Thought disorganization
Slide 22-

Schizophrenia Symptom Descriptions Negative symptoms Blunted affect - decreased facial expression, vocal inflection, eye contact, and expressive gestures Alogia - reduced amount of speech, reduced content of ideas, thought blocking, long latency Avolition/Apathy - poor grooming and hygiene, impersistence at school or work, low energy
Slide 23-

Schizophrenia Symptom Descriptions Negative symptoms Anhedonia/Asociality - loss of recreational interests, decreased sexual activity, absence of intimacy and personal relationships Inattention - socially uninvolved, “spacey,” poor cognitive function
Slide 24-

Schizophrenia Symptom Descriptions Cognitive impairment Memory Executive function Language Attention
Slide 25-

Schizophrenia Onset, Course, and Complications Age and circumstances of onset Prodromal symptoms may be present from birth or may precede psychosis by months or years. Poor social adjustment; few friends Poor school and work performance; low IQ Negative symptoms Peculiarities of thought or behavior
Slide 26-

Schizophrenia Onset, Course, and Complications Age and circumstances of onset Peak age of onset for men is 17-30 Peak age of onset for women is 20-40
Slide 27-

Schizophrenia Prognostic Features Adapted from: Sadock BJ, Sadock VA: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 7th ed, Philadelphia, Lippincott Williams & Wilkins, p. 1197
Slide 28-

Schizophrenia Clinical Course Prodromal symptoms typically predate the diagnosis by months or years Positive symptoms tend to occur episodically acute episodes are the most common cause of hospitalization, and respond well to antipsychotic medication (Cont.)
Slide 29-

Schizophrenia Clinical Course (Cont.) Negative symptoms tend to be chronic and progressive, are correlated with social and occupational deterioration, and respond poorly to treatment Residual symptoms tend to remain even when other symptoms are well controlled
Slide 30-

Clinical Course of Schizophrenia M. Jibson
Slide 31-

Schizophrenia Complications Suicide – 5-10% of deaths Depression - occurs in 50% of cases, often after an acute episode Homelessness – 30-35% of homeless Crime: 4-fold increase in acts of violence compared with the general population. These patients are more frequently victims of both violent and nonviolent crimes. Substance abuse
Slide 32-

Schizophrenia Epidemiology Prevalence and social distribution The lifetime risk of schizophrenia is 1% in all populations Annual incidence is 15-20 per 100,000 Over-representation of lower socioeconomic groups is probably the result of downward drift
Slide 33-

Schizophrenia Epidemiology Genetic factors 10% risk to first-degree relatives 50% risk to monozygotic twins No specific genetic linkage has been demonstrated Multiple genes are probably involved
Slide 34-

Schizophrenia Epidemiology Prenatal and perinatal complications In utero and perinatal infection 2nd trimester viral infections Winter births Toxic exposure Perinatal anoxia
Slide 35-

Schizophrenia Epidemiology Multi-hit Hypothesis A combination of genetic vulnerability and environmental insults is required to develop the disorder
Slide 36-

Schizophrenia Pathophysiology The cause of schizophrenia is unclear, but the following are considered to have a role: Dopamine hypothesis Structural correlates Other hypotheses
Slide 37-

Major Dopamine Pathways 1. Nigrostriatal tract- (extrapyramidal pathway) begins in the substantia nigra and ends in the caudate nucleus and putamen of the basal ganglia 2. Mesolimbic tract - originates in the midbrain tegmentum and innervates the nucleus accumbens and adjacent limbic structures 3. Mesocortical tract - originates in the midbrain tegmentum and innervates anterior cortical areas 4. Tuberoinfundibular tract - projects from the arcuate and periventricular nuclei of the hypothalamus to the pituitary Hales RE, Yudofsky SC. Textbook of Neuropsychiatry. American Psychiatric Press, 1987
Slide 38-

Dopamine Hypothesis of Schizophrenia Evidence for involvement Increased dopamine receptors at autopsy Dopamine agonists and re-uptake blockers worsen psychosis All effective neuroleptics block post-synaptic dopamine actions Good responders to neuroleptics have progressive decrease in plasma HVA (dopamine metabolite), while poor responders do not
Slide 39-

Dopamine Hypothesis of Schizophrenia Model for dopamine involvement Increased subcortical dopamine activity Decreased prefrontal dopamine activity
Slide 40-

Dopamine Hypothesis of Schizophrenia Structural correlates Increased ventricle-to-brain ratio Most frequently replicated finding in schizophrenia research Not associated with any specific brain structure or pathway
Slide 41-

Dopamine Hypothesis of Schizophrenia Other Hypotheses Alterations in glutamate neurotransmission involving the NMDA receptor Aberrant GABA neurotransmission in the dorsolateral prefrontal cortex
Slide 42-

Schizophrenia Treatment Psychopharmacology - Antipsychotic medications Atypical antipsychotics (risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole) First-line drugs of choice - 70% of patients respond Clozapine is effective in 35-50% of patients who do not respond to other antipsychotics (80-85% of all patients) Conventional antipsychotics (neuroleptics) 70% of patients respond
Slide 43-

Schizophrenia Treatment Psychosocial interventions Case Management - essential for other interventions to be effective Finances Housing Social support network
Slide 44-

Psychosocial Support System Provide basic necessities: Finances Housing Personal support network All other treatments require these to be in place Community-based Interdisciplinary Treatment Team
Slide 45-

Schizophrenia Treatment Psychosocial interventions Social skills training Vocational rehabilitation Family psychoeducation – especially for families with high levels of “expressed emotion” Supportive psychotherapy
Slide 46-

Mood Disorders Manic Episode Psychosis Occurs in ~80% of manic episodes (lifetime risk is about 1%) Often mood congruent (e.g., grandiose delusions), but may be indistinguishable from psychotic symptoms of schizophrenia or other disorders May include catatonia Insight tends to be good between episodes, but very poor during the episodes
Slide 47-

Mood Disorders Manic Episode Treatment Antipsychotics – for acute episodes Mood stabilizers – for acute episodes and prophylaxis
Slide 48-

Mood Disorders Major Depressive Episode with Psychotic Features Psychosis 10% of depressed patients develop psychotic features (lifetime risk is about 1%) Often congruent with mood (e.g., nihilistic, persecutory, punishment, somatic)
Slide 49-

Mood Disorders Major Depressive Episode with Psychotic Features Treatment ECT is effective in 80-90% of patients Antipsychotic plus an antidepressant work in about 50% of cases (neither works well alone)
Slide 50-

Other Psychotic Disorders Schizoaffective Disorder Diagnostic criteria Course of illness includes periods of psychosis without mood symptoms and periods of psychosis with mood symptoms The psychotic and mood symptoms are both prominent during the course of illness
Slide 51-

Other Psychotic Disorders Schizoaffective Disorder DSM-IV-TR, pp. 323
Slide 52-

Other Psychotic Disorders Schizoaffective Disorder Less common than schizophrenia Treatment includes antipsychotic plus mood stabilizer or antidepressant
Slide 53-

Other Psychotic Disorders Delusional Disorder Diagnostic criteria Isolated, nonbizarre delusions Without other symptoms or impairments
Slide 54-

Other Psychotic Disorders Delusional Disorder DSM-IV-TR, pp. 329
Slide 55-

Other Psychotic Disorders Delusional Disorder Onset is in middle or late life Lifetime risk: 0.05% Course is variable Treatment of choice is antipsychotics, but the symptoms respond less well than in other psychotic disorders
Slide 56-

Other Psychotic Disorders Brief Psychotic Disorder Diagnostic criteria Psychosis that quickly resolves, with no residual impairment
Slide 57-

Other Psychotic Disorders Brief Psychotic Disorder DSM-IV-TR, pp. 332
Slide 58-

Other Psychotic Disorders Brief Psychotic Disorder Major predisposing factor is a personality disorder, especially paranoid, borderline, histrionic, narcissistic, or schizotypal Course tends to be characterized by rapid onset and rapid resolution Treatment usually includes antipsychotic medications, but symptoms often remit with only supportive care (e.g., hospital milieu, reduction in stress, resolution of interpersonal crisis)
Slide 59-

Other Psychotic Disorders Shared Psychotic Disorder (“Folie a Deux”) A delusion that develops in the context of a close relationship to another person with an established delusion
Slide 60-

Other Psychotic Disorders Alcohol Amphetamine (including MDMA) Cannabis Cocaine Hallucinogens Inhalants Opioids Phencyclidine (PCP) Sedatives, hypnotics, anxiolytics Substance-Induced Psychotic Disorder Psychosis associated with intoxication
Slide 61-

Other Psychotic Disorders Alcohol Sedatives, hypnotics, anxiolytics Substance-Induced Psychotic Disorder Psychosis associated with withdrawal
Slide 62-

Other Psychotic Disorders High-dose steroids L-Dopa Substance-Induced Psychotic Disorder Psychosis associated with medical treatment
Slide 63-

Other Psychotic Disorders Psychotic Disorder Due to a General Medical Condition Adapted from: Stoudemire A: Clinical Psychiatry for Medical Students, 3rd ed, Philadelphia, Lippincott-Raven, 1998, p. 122
Slide 64-

Other Psychotic Disorders Psychotic Disorder Due to a General Medical Condition Delirium Dementia
Slide 65-

Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy Slide 16: American Psychiatric Association: Diagnostic and Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR), Washington, DC, American Psychiatric Association, 2000, p. 312 Slide 29: Adapted from: Sadock BJ, Sadock VA: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 7th ed, Philadelphia, Lippincott Williams & Wilkins, p. 1197 Slide 32: Michael Jibson Slide 39: Hales RE, Yudofsky SC. Textbook of Neuropsychiatry. American Psychiatric Press, 1987 Slide 53: DSM-IV-TR, pp. 323 Slide 56: DSM-IV-TR, pp. 329 Slide 59: DSM-IV-TR, pp. 332 Slide 65: Adapted from: Stoudemire A: Clinical Psychiatry for Medical Students, 3rd ed, Philadelphia, Lippincott-Raven, 1998, p. 122