Schizophrenia and Other Psychoses • Women are more compliant with medications

Three inescapable “facts” about schizophrenia: • Women tend to have lower blood levels and

• 1. Age at onset: late adolescent and early longer half-lives of medications

adulthood
Epidemiology of Schizophrenia
• 2. Role of stress: Onset and relapse always
• 1% of the population develops schizophrenia
related to stress
• 95% suffer lifetime
• 3. Efficacy of Dopamine Antagonist: Drugs
that block dopamine receptors are • 50% experience serious side effects from
therapeutic medications

• Psychosis – is a disruptive mental state in • 10% kill themselves

which an individual struggles to distinguish
Four A’s of Schizophrenia (Bleuler)
the external world from internally generated
perception. • Affective disturbance – inappropriate, or
flattened affect
Differentiate Neurosis from Psychosis as to:
• Autism – preoccupation with the self, with
• Personality
little concern for external reality
• Reality
• Associative looseness – the stringing together
• Insight of unrelated topics

• Delusion • Ambivalence – simultaneous opposite

feelings
• Causes
Course of Illness (overlapping phases)
Schizophrenia
• Acute Phase – the patient experience severe
• Is a diagnostic term used to describe a major
psychotic symptoms
psychotic disorder characterized by
disturbances of the following: • Stabilizing Phase – the patient is getting
better
– Perception (hallucinations)
• Stable Phase – the patient might still
– Thought processes (thought derailment)
experience hallucinations and delusions but
– Reality testing (delusions) not as severe or disabling as they were during
the acute phase
– Feeling (flat or inappropriate affect)
DSM IV TR Criteria
– Behavior (social withdrawal)
A. Characteristics Symptoms (at least 2 of the
– Attention (inability to concentrate) following)
– Motivation (cannot initiate or persist in goal- • Delusions
directed activities)
• Hallucination
• Formerly known as Dementia Pracox (Emil
Kraeplin) • Disorganized speech

• Age of onset in men is typically 4 to 6 years • Grossly disorganized or catatonic behavior

earlier than it is in women
• Negative Symptoms
• Men have a more severe course
B. Social – occupational dysfunction: work,
• Women have more positive symptoms interpersonal, and self-care functioning below the
level achieved before onset
• Estrogen modulates dopamine function
 C. Duration: continuous signs of the disturbance Objective Signs
for at least 6 months
• Alterations in Personal Relationships
D. Schizoaffective and mood disorders not
- Decreased attention to appearance and social
present and not responsible for the signs and
amenities related to introspection and autism
symptoms
- Inadequate or inappropriate communication
E. Not caused by substance abuse or a general
medical disorder. - Hostility
Types of Delusion - Withdrawal
• Erotomatic Alterations of Activity
• Grandiose - Psychomotor agitation
• Jealous - Catatonic rigidity
• Persecutory - Echopraxia
• Somatic - Stereotypy
• Mixed or Unspecified Subjective Symptoms
• Religious • Altered Perception
• Nihilistic - Hallucination (auditory, visual, olfactory, tactile,
gustatory)
• Paranoid
- Illusion (misinterpretation of real external
• Delusion of Influence
stimuli)
• Delusion of Reference
- Paranoid thinking
Positive versus Negative Schizophrenia
• Alteration of Thought
Type 2: Negative Symptoms
- Loose associations
• Alogia
- Retardation (slowing of mental activity)
• Anergia
- Blocking (interruption of thought and inability to
• Asocial behavior recall it)

• Attention deficits - Autism (introspective/own world)

• Avolition - Ambivalence (love-hate)

• Blunted affect - Delusions (fixed, false beliefs)

• Communication difficulties - Poverty of Speech (inability to formulate and

articulate thoughts, vocabulary is limmitted)
• Difficulty with abstraction
- Ideas of reference
• Passive social withdrawal
- Mutism
• Poor grooming and hygiene
- Concrete thinking (inability to conceptualize the
• Poor rapport
meaning of words)
• Poverty of speech
• Altered consciousness

- Confusion

- Incoherent speech (difficult to understand)

 - Clouding (mental fog) Psychotherapeutic NPR

- Sense of “going crazy” (loss of control) • Be calm when talking to patients

• Alterations of Affect • Accept patients as they are, but do not accept

all behaviors
- Inappropriate, blunted, flattened, or labile affect
• Keep promises
- Apathy
• Be consistent
- Ambivalence
• Be honest
- Overreaction
• Do not reinforce hallucinations and delusions
- Anhedonia
• Orient patients to time, person, and place, if
Etiology
indicated
• Biochemical Theories
• Do not touch patients without warning them
• Neurostructural Theories (Brain Athropy,
• Avoid whispering or laughing
Cerebral Blood Flow)
• Reinforce positive behaviors
• Genetic Theories
• Avoid competitive activities with some
• Perinatal Risk Factors
patients
• Family Theories
• Do not embarrass patients
• Vulnerability – Stress Model – biologic and
• For withdrawn patients, start with one to one
psychodynamic predispositions coupled with
interactions
stress
• Allow and encourage verbalization of feelings
Developmental Theories of Schizophrenia
Psychotherapeutic Principles
• -Sigmund Freud – poor ego boundaries,
superego dominance 1. NPR Principles

• - Erikson – trust vs. mistrust – Focus on behavior

• - Sullivan – absence of warm, nurturing – A long term relationship is most

attention can result disordered social therapeutic
interactions
– Accept patient but not all behaviors
Types
– Be consistent
• 1. Paranoid (HIDS)
– Do not reinforce hallucinations and
• 2. Disorganized (SIM) delusions

• 3. Catatonic (WAN) – Avoid whispering or laughing if

patient cannot hear all of
• 4. Undiffentiated
conversation
• 5. Residual
2. Psychotropic Drugs
Depression and Suicide in Schizophrenia
A. Traditional Antipsychotics
• 1. Depression is a natural part of
– Haloperidol (Haldol)
schizophrenia
– Fluphenazine Decanoate (Fluxim)
• 2. Depression is a reaction to schizophrenia
– Chlorpromazine (Thorazine)
• 3. The biologic nature of the disorder and the
drugs used to treat it
 B. Atypical Antipsychotics
by:
– Clozapine (Leponex)
– Risperedone (Risperdal)
– Olanzapine (Zyprexa)
– Quetiapine (Seroquel)
– Aripiprazole (Abilify)
Major Side Effects of Antipsychotic Drugs
• EPSE
– Parkinsonism
– Akathisia
– Dystonia
– Neuroleptic Malignant Syndrome
(NMS)
– Pisa Syndrome
• Anticholinergic Effects
– Dry mouth
– Blurred vision
– Constipation
– Urinary hesitation
– Tachycardia
• Tardive Dyskinesia
• Elevated prolactin (ammenorhea,
galactorrhea, impotency, decreased libido)
Other Psychotic Disorders
• Sedation
• Orthostatic Hypotension
3. Milieu Management Principles
• Milieu – therapeutic manipulation of the
environment
– Modify environment to decrease
stimulation and for safety
– Staff consistency is crucial
– Arrange environment to reduce
withdrawn behavior
– Monitor television watching
– Protect patient’s self esteem
Address the Environment of Schizophrenic Patients
For disruptive patients:
– Set limits on disruptive behavior
– Decrease environmental stimuli
– When using restraints, provide safety
For withdrawn patients:
– Arrange non threatening activities
– Arrange furniture in semi-circle
– Help to participate in decision making
For patients with impaired communication:
– Be patient, do not pressure patient to
make sense
– Do not place patient in group
activities that would frustrate them
– Provide opportunities for purposeful
psychomotor activities
For patients with hallucinations:
– Provide distracting activities
– Monitor television selections
For disorganized patients:
– Provide calm environment
– Provide safe and simple activities
• Schizoaffective Disorder
– Is a psychosis characterized by both
affective (mood disorder) and
schizophrenic (thought disorder)
symptoms with substantial loss of
occupational and social functioning.
– Schizophrenic symptoms are
dominant but are accompanied by
major depressive or manic symptoms.
– Prognosis is better than schizophrenia
• Delusional Disorder
– Display symptoms similar to those
seen in patients with schizophrenia.
However, substantial differences exist
and necessitate a diagnostic
 differentiation. The following
symptoms differentiate delusional
disorders from schizophrenic
disorders:
• Delusions have basis in reality
• The patients have not met the
criteria for schizophrenia
• The behavior is relatively
normal except in relation to
their delusions
• If mood episodes have
occurred concurrently with
delusions, their total
durations, their total duration
has been relatively brief.
• The symptoms are NOT the
direct result of a substance-
induced or medical condition.
• Brief Psychotic Disorder
– Includes all psychotic disturbances
that last less than one month and are
not related to mood disorder, a
general medical condition, or a
substance induced disorder
– At least one of the following
disturbances must be present:
delusions, hallucinations, disorganized
speech, or grossly disorganized or
catatonic behavior.
• Schizophreniform Disorder
– Displays symptoms that are typical of
schizophrenia and last at least one
month but no longer than six months.
– This cautious approach spares the
individual the lifelong diagnosis of
schizophrenia until professionals are
absolutely sure of the diagnosis.
Personality Disorders
DSM IV TR Personality Disorders
Cluster A – Odd, Eccentric Behaviors
1. Paranoid Personality Disorder
2. Schizoid Personality Disorder
3. Schizotypal Personality Disorder
Cluster B – Dramatic, Emotional, Erratic Behaviors
1. Antisocial Personality Disorder
2. Borderline Personality Disorder
3. Histrionic Personality Disorder
4. Narcissistic Personality Disorder
Cluster C – Anxious, Fearful Behaviors
1. Avoidant Personality Disorder
2. Dependent Personality Disorder
3. Obsessive – compulsive Personality Disorder
Cluster A
• Paranoid Personality Disorder
– Suspiciousness and mistrust of people
– Transient psychotic symptoms might
be precipitated by stress
– Interprets actions of others as
personal threats
– Hypersensitive to other people’s
motives and feel vulnerable because
they think other treat them unfairly.
– Unable to laugh at themselves and are
often humorless, rigid and guarded.
– Speech are logical and goal-directed
– Blunted affect so they might appear
to be cold
– Prejudice and sometimes ideas of
reference
• Schizoid Personality Disorder
– Do not want to be involved in
interpersonal or social relationships
and keep people at an emotional
distance.
– Rarely have friends and appear
uncomfortable interacting with
others.
– Respond with short answers to
questions and do not initiate
spontaneous conversation.
– Can function in work successfully if
they can work in isolation
 – Solitary activities are gratifying
suicidality.
• Schizotypal Personality Disorder
– Appear similar to schizophrenia and
do not meet enough of the criteria to
be diagnosed with psychosis or
schizophrenia.
– Problems in thinking, perceiving and
communicating
– Outward appearance maybe eccentric
and their thinking and behavior odd.
– Sensitive to the behaviors of others
especially rejection and anger and
feel they are different and do not fit
in.
– Paranoid ideation, ideas of reference
and odd beliefs are most prevalent
and unchangeable criteria
– Superstitious
Cluster B
• Antisocial Personality Disorder
– Pattern of disregard for the rights of
others, which is usually demonstrated
by repeated violations of the law.
– They abuse alcohol and other
substances and can be promiscuous
and feel no guilt of hurting others.
– Lying, cheating and stealing are
common.
– Use others to their advantage and do
not assume responsibility for their
behaviors
– They may appear to be charming and
intellectual
– They are smooth talkers and deny and
rationalize their behavior
– As is do not have conscience
– Before age 15 (Conduct Behavior)
• Borderline Personality Disorder
– Emotional dysregulation, anger,
impulsivity, unstable relationship,
identity or self image
disturbance, abandonment, fear, self mutilation and
– Interpersonal relationship are chaotic,
problems exist in choosing unhealthy
relationships and short term intimate
relationships
– Sexual impulsiveness is seen in casual
sex relationships and multiple sexual
partners
– Alternates between overidealization
and devaluation of individuals
– Great difficulty of being alone and
therefore seeks an intense but brief
relationships
– Projective identification is used to
protect self
– Common impulsive activity include
overspending, promiscuity,
compulsive overeating and unhealthy
risk taking and decision
– Most commonly treated
• Narcissistic Personality Disorder
– Displays grandiosity about his or her
importance and achievements.
– Grandiosity is unlike delusions of grandeur.
– The grandiosity is based somewhat in reality
but distorted, embellished, or convoluted to
– meet the patient’s needs of self-importance.
– Two subtypes are: malignant (grandiose,
arrogant and entitled) and fragile (self
inhibited but has grandiose expectations of
self and others)
– Malignant narcissistic patient overvalues
himself or herself, needs to be admired, is
arrogant, self-centered and self absorbed,
seems indifferent to the criticisms of others.
This patient harbors much anger and does
not experience feelings of inadequacy but
feels superior to others and wants power and
control. Manipulation and demands are part
of how this patient relates with others.
– Fragile narcissism might appear nonchalant or
indifferent to criticism while hiding feelings of
anger, rage or emptiness. Constant
 reinforcement from others is needed to boost – Feel inadequate and are hypersensitive to
self- esteem. Relationship might be shallow, criticism, fearful and shy.
might empathize with others but is very self
– Desire relationship but need to be certain of
centered. Use others selfishly to meet their
being liked before
own needs.
– making social contacts
• Histrionic Personality Disorder
– To keep their anxiety at a minimal level, they
– Dramatizes events and draws attention to self.
avoid situations in which they might be
– Extrovert and thrives on being the center of disappointed or rejected.
attention. Behavior is silly, colorful and
– Lacks self confidence or afraid to ask question
seductive.
or speak up in public,
– Speech is vague, descriptive, superficial,
– withdraws from social support and conveys
lacking in detail, insight and depth.
helplessness
– Seems to be in a hurry and restless. Temper
• Obsessive Personality Disorder
tantrums and outbursts of anger are
– Perfectionist and inflexible, overly strict and
– seen and overreactions to minor events.
often set standards for themselves that are
– Might use somatic complaints to avoid too high, thus their work is never good
responsibility and support dependency. enough

– Can not deal with his or her own feelings, – Preoccupied with rules and trivial details and
views relationships with others as special or procedures.
possessing greater intimacy than is real.
– They find it difficult to express warmth and
– Recently met individuals are thought of as tender emotions. They are
being dear friends.
– rigid controlling and cold.
• Dependent Personality Disorder
– Serious about all of his activities so having fun
– Pervasive and excessive need to be cared of or experiencing pleasure is difficult.
that leads to submissive and clinging
– Afraid of making mistakes, he or she can be
behaviors and fears of separation.
indecisive or will put off
– They want others to make daily decisions for
– decisions until all the facts have been
them. They need direction and reassurance.
obtained.
– Feel inferior and cling to others excessively
– Constricted affect and speak in a monotone
because they are afraid that they will

– be left alone.

– Avoiding responsibility and expressing

helplessness, they maintains the need to rely
on others.

– Perceive themselves as being unable to

function without the help of others.

– Intimate relationship with abusive, unfaithful

or alcoholic spouse is tolerated so as

– not to disturb the sense of attachment.

• Avoidant Personality Disorder

– Timid, socially uncomfortable and withdrawn