Psychiatry 2 SCHIZOPHRENIA

AY 2021-2022 Dr. Igot, MD

1st Shift 08-18-21

SCHIZOPHRENIA

● Hypothesized that the defect in ego functions

SPECTRUM OF SCHIZOPHRENIA
I. SCHIZOTYPAL PERSONALITY DISORDER
II. DELUSIONAL DISORDER
III. BRIEF PSYCHOTIC DISORDER
IV. SCHIZOPHRENIFORM DISORDER V.
SCHIZOPHRENIA VI. SCHIZOAFFECTIVE
DISORDER
VII. SUBSTANCE/MEDICATION-INDUCED
PSYCHOTIC DISORDER
VIII. PSYCHOTIC DISORDER DUE TO
ANOTHER MEDICAL CONDITION
IX. CATATONIA ASSOCIATED WITH ANOTHER
MENTAL DISORDER (CATATONIA SPECIFIER)
X. CATATONIC DISORDER DUE TO ANOTHER
MEDICAL CONDITION
XI. UNSPECIFIED CATATONIA
XII. OTHER SPECIFIED SCHIZOPHRENIA
SPECTRUM AND OTHER PSYCHOTIC
DISORDER
XIII. UNSPECIFIED SCHIZOPHRENIA
SPECTRUM AND OTHER PSYCHOTIC
DISORDER
PSYCHOANALYTIC THEORIES OF
SCHIZOPHRENIA
Sigmund Freud
● Postulated that schizophrenia resulted from
developmental fixations early in life
● Ego functions are impaired
o Interpreting reality
o Control of inner drives, such as sex
and aggression
Margaret Mahler
● There are distortions in the reciprocal
relationship between the infant and the
mother
● The child is unable to separate from, and
progress beyond, the closeness and
complete dependence that characterize the
mother-child relationship in the oral phase of
development
● Ergo: identity never becomes secure
Paul Federn
permits intense hostility and aggression to
distort the mother-infant relationship, which
leads to eventual personality disorganization
and vulnerability to stress
Harry Stack Sullivan
● Viewed schizophrenia as a disturbance in
interpersonal relatedness
● Massive anxiety creates a sense of
unrelatedness that is transformed into
parataxic distortions (usually persecutory)
● Schizophrenia is due to an adaptive method
to avoid panic, terror, and disintegration of
the sense of self
● Various symptoms of schizophrenia have
symbolic meaning for each patient, for
example:Fantasies of the world coming to an
end may indicate a perception
that a person’s internal world has broken down
● Feelings of inferiority are replaced by
delusions of grandeur and omnipotence
● Hallucinations may be substitutes for a
patient’s inability to deal with objective reality
may represent inner wishes or fears
● Delusions, similar to hallucinations, are
regressive, restitutive attempts to create a
new reality or to express hidden fears or
impulses
Learning Theories
● Poor models for learning during childhood
result to poor interpersonal relationship
DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA
(DSM 5ed)
Criterion A
● Two (or more) of the following, each present
for a significant portion of time during a 1-
month period (or less if successfully
treated).
At least one of these must be (1), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment
or incoherence)
4. Grossly disorganized or catatonic behavior

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 Psychiatry 2 SCHIZOPHRENIA
AY 2021-2022 Dr. Igot, MD
1st Shift 08-18-21
5. Negative symptoms (i.e., diminished emotional
expression or avolition)
Criterion B
● For a significant portion of the time since the
onset of the disturbance, level of functioning
in one or more major areas, such as work,
interpersonal relations, or self-care, is
markedly below the level achieved prior to
the onset (or when the onset is in childhood
or adolescence, there is failure to achieve
expected level of interpersonal, academic,
or occupational functioning)
Criterion C
● Continuous signs of the disturbance persist
for at least 6 months. This 6- month period
must include at least 1 month of symptoms
(or less if successfully treated) that meet
Criterion A (i.e., active-phase symptoms)
and may include periods of prodromal or
residual symptoms. During these prodromal
or residual periods, the signs of the
disturbance may be manifested by only
negative symptoms or by two or more
symptoms listed in Criterion A present in an
attenuated form (e.g., odd beliefs, unusual
perceptual experiences)
Criterion D
● Schizoaffective disorder and depressive or
bipolar disorder with psychotic features have
been ruled out because either
1) no major depressive or manic episodes
have occurred concurrently with the active-
phase symptoms, or
2) if mood episodes have occurred during
active-phase symptoms, they have been present for
a minority of the total duration of the active and
residual periods of the illness
Criterion E
● The disturbance is not attributable to the
physiological effects of a substance (e.g., a
drug of abuse, a medication) or another
medical condition
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Criterion F
● If there is a history of autism spectrum
disorder or a communication disorder of
childhood onset, the additional diagnosis of
schizophrenia is made only if prominent
delusions or hallucinations, in addition to the
other required symptoms of schizophrenia,
are also present for at least 1 month (or less
if successfully treated)
Specify if:
● The following course specifiers are only to be
used after a 1-year duration of the disorder
and if they are not in contradiction to the
diagnostic course criteria
● First episode, currently in a cute episode:
First manifestation of the disorder meeting
the defining diagnostic symptom and time
criteria.
● An acute episode is a time period in which
the symptom criteria are fulfilled
● First episode, currently in partial
remission: Partial remission is a period of
time during which an improvement after a
previous episode is maintained and in which
the defining criteria of the disorder are only
partially fulfilled
● First episode, currently in full remission:
Full remission is a period of time after a
previous episode during which no disorder-
specific symptoms are present
● Multiple episodes, currently in acute
episode: Multiple episodes may be
determined after a minimum of two episodes
(i.e., after a first episode, a remission and a
minimum of one relapse)
● Multiple episodes, currently in partial
remission
● Multiple episodes, currently in full
remission
● Continuous: symptoms fulfilling the
diagnostic symptom criteria of the disorder
are remaining for the majority of the illness
course, with subthreshold symptom periods
being very brief relative to the overall course
EPIDEMIOLOGY
● Worldwide prevalence: 0.5% - 1%
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 Psychiatry 2 SCHIZOPHRENIA
AY 2021-2022 Dr. Igot, MD
1st Shift 08-18-21

● Can develop at any age ➢ Disorganized motor and social

● Age of onset: men (18-25 y.o.); women (21- behavior
30 y.o.) o Catatonic stupor o Echopraxia
● Common among single and no children o Catatonic excitement o Automatic obedience
● High risk for suicidal behavior o 1/3 of o Stereotypy o Negativism
schizophrenics attempt suicide because of o Mannerisms
command hallucinations

o 1 in 10 suicidal schizophrenics die because of SUBTYPES OF SCHIZOPHRENIA

suicide (complete suicide) I. PARANOID TYPE
● Preoccupation with 1 or more delusions or
o Risk factors: frequent auditory hallucinations
● Mainly characterized by delusions of
➢ Male Less than 30 y.o. persecution or grandeur
➢ Unemployed ● First episode at an older age
➢ Chronic course ● Ego resources are greater
➢ Prior depression ● Less regression of mental facilities,
➢ Past treatment for depression emotional responses, and behavior
➢ Substance abuse ● Tense, suspicious, guarded, reserved,
➢ Recent hospital discharge sometimes hostile and aggressive
● Occasionally adequately conduct
DIMENSIONS themselves socially

Psychotic Dimension II. DISORGANIZED TYPE

● Hallucinations ● Marked regression to primitive, disinhibited,
and unorganized behavior
o Perceptions experienced without an ● Absence of symptoms that meet criteria for
external stimulus catatonic type
o Auditory, visual, tactile, gustatory, olfactory ● Earlier onset (less than 25 y.o.)
● Usually active: aimless and non-constructive
● Delusions ● Poor contact with reality
o Disturbance in thought rather than ● Disheveled
perception ● Inappropriate social behavior and emotional
o Firmly held beliefs that are untrue responses
and as well as contrary to a person’s ● Incongruous behavior: silly or fatuous
educational and cultural background
III. CATATONIC TYPE
-Grandiose - Nihilistic ● Rare in Europe and North America
-Persecutory -Somatic ● Marked disturbance in motor function
-Sexual -Religious ● Stupor, negativism, rigidity, excitement,
● Negative Dimension posturing
- Anhedonia ● Usually active: aimless and non-constructive
-Alogia ● Sometimes with rapid alteration: excitement
-Avolition stupor
-Diminished emotional expression ● Stereotypies, mannerisms, mutism, and
(affective flattening or blunting) waxy flexibility
● SUPERVISE: prevent from hurting self or
● Disorganization Dimension others
➢ Disorganized speech or thought ● MEDICAL CARE: malnutrition, exhaustion,
disorder hyperpyrexia, self-inflicted injury

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 Psychiatry 2 SCHIZOPHRENIA
AY 2021-2022 Dr. Igot, MD
1st Shift 08-18-21

IV. RESIDUAL TYPE

● Absence of complete set of active symptoms
or sufficient symptoms
● Emotional blunting, social withdrawal,
eccentric behavior, illogical thinking, and
mild loosening associations
V. UNDIFFERENTIATED TYPE
● Schizophrenia that cannot fit in one type or
another

TYPICAL STAGES OF SCHIZOPHRENIA

PHASES OF TREATMENT
Treatment of Acute Psychosis
 Require immediate attention
 Aims to alleviate the most severe psychotic
symptoms
 Acute schizophrenia is typically associated
PROGNOSIS with severe agitation, which can result from
such symptoms as frightening delusions,
hallucinations, or suspiciousness
 Antipsychotics and benzodiazepines can
result in relatively rapid calming of patients
 IM injection of antipsychotic resulting in
calming effect without excessive sedation:
o Haloperidol (Haldol), fluphenazine
(Prolixin, Permitil), olanzapine
(Zyprexa), or ziprasidone (Geodon)
 IM ziprasidone and olanzapine do not cause
substantial extrapyramidal side effect (EPS)
during acute treatment

Stabilization and Maintenance Phase
 In this phase, the illness is in a relative stage
of remission
 Goal is to prevent psychotic relapse and to
assist patients in improving their level of
functioning

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 Psychiatry 2 SCHIZOPHRENIA
AY 2021-2022 Dr. Igot, MD
1st Shift 08-18-21

 16-23% of patients receiving treatment will

experience a relapse within 1 year
 53-72% will relapse without medications
 Stopping medication increases relapse risk
by fivefold

CLINICAL MANAGEMENT

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