Dr .

Nuha AlShammari
Consultant Psychiatrist
First Episode Psychosis\Youth
Crisis Management
Department of Psychiatry
IAFU University
ž Generic term
ž “Break with Reality”
ž Symptom, not an illness
ž Caused by a variety of conditions that
affect the functioning of the brain.
ž Includes hallucinations, delusions and
thought disorder
ž 22 y man was brought to the
emergency room by the police after
he started screaming at Starbucks
then threw coffee at the cashier.
ž In the emergency room he stated “
FBI are going to catch me and put me
in Jail. Don’t get near me…”you all
work for FBI.
ž Good clinical history
ž Physical exam, ROS
ž Labs/Diagnostic tests:

CBC, Lytes URINE DRUG SCREEN!!!

Urinalysis
RFT LFT
Thyroid profile
CT or MRI
EEG
 Differential Diagnosis

P
Mood disorders
S
Substance
Y induced
OCD C
PD “organic”
H Medical mental
“Functional” O Conditions disorders
disorders S
Schizophrenia
“spectrum”
I Delirium
disorders S
 Work up Results

§ physical exam unremarkable

§ Pt. is fully oriented

§ No waxing/waning level of consciousness

§ All labs are unremarkable.

§ Drug Toxicology is negative

 Psychiatric Hx and
Mental Status Examination

§ No evidence of mood episodes

§ No OCD and personality Disorders

§ + Paranoid Delusions

§ Poor insight and limited Judgment

 Differential Diagnosis

P
Mood disorders
S
Substance
Y induced
OCD C
PD “organic”
H Medical mental
“Functional” O Conditions disorders
disorders S
Schizophrenia
“spectrum”
I Delirium
disorders S
ž Schizophrenia
ž Schizophreniform Disorder
ž Brief Psychotic Disorder

ž Schizoaffective Disorder
ž Delusional Disorder
 Onset Symptoms Course Duration
Schizo- Usually Delusions Chronic >6 months
insidious Hallucinations
phrenia
Disorganized
Negative Sx
Functioning

Schizophren Varies Varies limited 1-6 mo.

(usually
iform insidious)
Disorder
Brief Sudden Varies Limited <1 mo.

psychotic
disorder
 Onset Symptoms Course Duration

Schizoaffe Usually Schizophrenia Chronic >6

insidious + months
ctive
Mood Disorder
Disorder
Delusional Varies Delusions only Chronic >1 mo.
(usually
disorder insidious)
Organic Sudden Varies Limited Varies
Visual Halluc
Psychosis
disorientation <1 mo.
 How to diagnose ?

§ + paranoid Delusions

§ + Auditory Hallucinations

§ Onset 6 months ago

§ Patient is currently divorced and jobless

§ Poor insight and limited Judgment

ž Psychotic
symptoms (2 or more) for at least
one month
¡ Hallucinations
¡ Delusions
¡ Disorganized speech
¡ Disorganized or catatonic behavior
¡ Negative symptoms
ž Impairment in social or occupational
functioning
ž Duration of illness at least 6 mo.
ž Symptoms not due to mood disorder or
schizoaffective disorder
ž Symptoms not due to medical, neurological,
or substance-induced disorder
ž Paranoid/persecutory ž Religious delusions
ž Ideas of reference ž Somatic delusions
ž External locus of
control
ž Thought broadcasting
ž Thought insertion,
withdrawal
ž Jealousy
ž Guilt
ž Grandiosity
ž Auditory
ž Visual
ž Olfactory
ž Somatic \ tactile
ž Gustatory
ž Neologisms
ž Derailment
ž Tangentially
ž Loosening of associations (word salad)
ž Perseveration
ž Bizarre appearance
ž Catatonia
ž Poor impulse control
ž Anger
ž Agitation
Positive symptoms Negative symptoms
(Remember
Delusions Andreasen’s “A”s)
Hallucinations
Disorganized Behavior Affective flattening
Disorganized speech Alogia
Avolition
Anhedonia
Attentional impairment
ž Psychotic
symptoms (2 or more) for at least
one month
¡ Hallucinations
¡ Delusions
¡ Disorganized speech
¡ Disorganized or catatonic behavior
¡ Negative symptoms
ž Impairment in social or occupational
functioning
ž Duration of illness at least 6 mo.
ž Symptoms not due to mood disorder or
schizoaffective disorder
ž Symptoms not due to medical, neurological,
or substance-induced disorder
Paranoid Paranoid Delusions + Auditory Hallucinations
Affect not flat

Catatonic Motoric immobility or purposeless motor

activity, Rigid posture. Echolalia, Echopraxia

Disorganized Disorganized speech , Disorganized behavior

flat or inappropriate affect, not catatonic

Undifferentiat Probably most common

Mixed features
ed
Residual Met Criteria for Schiz, now resolved
(no hallucinations, no prominent Delusions)
but residual negative symptoms or
attenuated + Sx
ž 1% prevalence M=F

ž Onset M , early 20 F , late 20

ž Early, aggressive treatment decreases long-term

problems
Schizophrenia
ž Expressed emotion
ž Stressful life events
ž Low socioeconomic class
ž Limited social network
ž General population 1%
ž 1st degree relatives 10%
ž 2nd degree relatives 5%
ž Dizygotic twin 15%
ž Monozygotic twin 50%
ž Vulnerability to schizophrenia is likely
inherited
ž “Heritability” is probably 60-90%
ž Schizophrenia probably involves dysfunction
of many genes
ž Enlargement of lateral ventricles
ž Smaller than normal total brain volume
ž Cortical atrophy
ž Widening of third ventricle
ž Smaller hippocampus
ž Generally normal global cerebral flow
ž Hypofrontality
ž Failure to activate dorsolateral prefrontal
cortex (problem-solving, adaptation, coping
with changes)
ž Alltypical antipsychotics block D2
with varying affinities
ž Dopamine agonists can precipitate a
psychosis
¡ Amphetamines
¡ Cocaine
¡ L-dopa
Schizophrenia
 GOOD Poor
Late onset Early Onset
Obvious precipitators No precipitators
Acute onset Insidious Onset
Good Premorbid Functioning Poor premorbid Functioning
Mood Disorder or family Hx No Mood Disorder Sx

Married Single , divorced or widowed

Female sex Withdrawn ,autistic behavior
Poor Support system
Good Support System
Positive Symptoms Negative Symptoms
Many relapses , Forensic
Neuro Sx, Perinatal Trauma
ž 1/3 somewhat normal life

ž 1/3Significant sx but can function

within Society

ž 1/3markedly impaired and require

frequent hospitalization (10%
require long term hospitalization)

ž 10% Suicide rate

Schizophrenia
ž Acute Sx with disturbed behavior
ž Poor Insight and Judgment

ž Risk to himself or others

ž Typical
(1st or old ž Atypical (2nd
generation): generation ):

¡ Dopamine ž Dopamine and

antagonists Serotonin Antagonists
 Clinical
Cell bodies Projections Functions implications

Nigro- Substantia Caudate

and
Move-
ment
Extrapyramidal
symptoms, dystonias,
Nigra
striatal putamen Tardive dyskinesia

Meso- Ventral
tegmental
Accumbens
amygdala
Emotions, Positive symptoms
affect,
limbic area, subst. Olfactory memory
nigra tubercle

Meso- Ventral
tegmental
Prefrontal Thought,
volition,
Blockade here can
worsen negative
Cortex
cortical area memory symptoms.
ž Low potency: ž High potency:
¡ Chlorpromazine ¡ Haloperidol
ž Extra pyramidal Side effects
Acute dystonia
Parkinsonian side effects (EPS)
Akathisia
Tardive dyskinesia

ž Sedation,orthostasis, QTC prolongation,

anticholinergic, lower seizure threshold, increased
prolactin
ž Risperidone
ž Olanzapine

ž Aripiprazole
ž Quetiapine
ž Clozapine
ž spectrum of receptor activity (Serotonin,
dopamine, GABA)
ž May be better at alleviating negative
symptoms and cognitive dysfunction
ž Sedation
ž Weight Gain
ž Hyperglycemia, new-onset diabetes
ž Hypercholeserolemia
ž Anticholinergic effects
ž prolactin elevation

ž Some EPS
ž Education, compliance #1
ž Families should be involved
ž Supportive Psychotherapy
ž Cognitive Behavioral Therapy
ž Social skills training
ž Group therapy