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Dr.Deddy Soestiantoro Sp.KJ M.Kes



: Morel -------------Demence precoce

: Hecker------------Hebephrenia
: Kahlbaum--------Katatonia
: Kraepelin---------Dementia praecoc
: Adolf Meyer----Adaptation reaction
: Eugen Bleurer---Schizophrenia

Around 0,3 % population , 60 % mental hospital
I. -Heredoconstitutional factor:
the possibility of schizophrenia:
-one parent (+) , children 7-16 % (+)
-all parent (+) , children 40 %
-monozygotic twin ----85,8 %
-dizygotic twin -------14 %
II. -Psychogenic factor
III. -Exogenic factor

-Attention and initiative markedly decrease
-Lazy, lack of self care
-Psychical contact limited,monosyllable, poker face
-Flat affect , emotion difficult to feel, no empaty
-Concentration decrease, discriminative insight disturbed,
but no dementia
-Thought process: association disorders--incoherence,often
with delusion and hallucination. Dereistic thinking, neologisme,
hemmung & sperrung.Sometimes there are depersonalization &
-Behavioural symptoms: abulia or hypobulia and also often

Usually there's pre-schizophrenic periode around

2 years, e.g
-emotional withdrawl, appearing faraway , apathy,
feeling unwelcome, lack of social contacts,
begining lack of nuance feeling, and finally
went to poor emotional life & dysharmonious
so it finally become unfelt and inapropriate.
The symptoms above are similar with the residual type
which there's remission with sequelle.


-a certain psychotic characteristic during the
active phase,
-multiple specific psychological symptoms,
-onset before 45 years,
-minimal 3-6 months (PPDGJ-II),
-not because of affective /organic mental


-isolation,social impairment, bizzare behavior,lack of self care,
flat affect,blunted or inapropriate, unusual ideas or magical
thought,unusual perception e.g ilusion.
During the phase of the illness minimal there's one of the
following symtoms:
-bizzare delusion,controlled,broadcast/insertion/withdrawl,with
-somatic,megalomania,nihilistic delusions,
-delusion of persecution or jealousy with hallucination,
-auditoric hallucination-comment or dialogue
-auditoric hallucination not related to depression or euphoria

It's better to look the longitudinal history of the illness.
The classical subtypes of schizophrenia are:
-hebephrenia, catatonia and paranoid type (Kraepelin),
-simplex/simple type ( Bleurer).
Simple type
-slowly beginning, hallucination not frequent/rare,
-limited thought, inability to absstract thought,
-association disorders rare,
-bizzare behavior ass. with emotion,attention & activity.
Hebephrenic type
-rapid disintegration, very disturbed association, a lot of
incoherence, neologisme.
-bizzare delusions, frequent cheerfull hallucinations,
-severe regression, frequent mannerism, deep autism.
Catatonic type
-frequently as stupor or furor catatonic ,
-catalepsy symptoms or flexibilitas cerea.

Paranoid type
-predominant delusions with hallucinations
Schizophreiform disorder
-premorbid tends to normal,
-acute, during 2 weeks untill 6 months
-hazy conciousness,oneroid, double book-keeping
Schizoaffective type,
-dominant affective symptoms,
Laten type
-unclear symptoms, hide/silent
Residual type
-remission with residual symptoms

1.Eugen Bleurer: 4 As
Primary symptoms:-association disorders,
-affect disorders,
Secondary symptoms:-delusions,hallucinations etc.
2.Kurt Schneider:
First rank symptoms:
-halucinations;audible thought, dialogue,commentary
-somatic passivity experience,
-thought process:
-interruption/thought withdrawl,thought broadcast,
-delusional peceptions,
-changing desire-

3.PPDGJ (according to ICD & DSM )

In PPDGJ III schizophrenia is in Group II
Hierarchi of Mental Illness Block Diagnosis
( F20-F29 ) where more completely
ass.with schizotypal disorder , acute &
transient psychotic disorders which can be
followed by schizophrenic symptoms and
also schizophrenic-like type ,and post
schizophrenic depression.

-Mental organic disorders
-Other functional psychosis
-Hysteria/Dissociative dsisorders
-Beliefs, tradition, religious


II.Somatic treatments/biological therapies
usually using major tranquillizers (antipsychotic/neuroleptic drugs),
first choice is the classic typical antipsychotic and if no progress use
the newer generation of drugs it's the atypical antipsychotic drugs
-other drugs : lithium,anticonvulsants,benzodiazepines
-other biological therapies
-ECT as the last choice if there's no progress in drugs therapy
III.Psychosocial therapies
-Social skills training
-Family-oriented therapies
- Case management
-Assertive community treatment(ACT)
-Group therapy
-Cognitive behavioral therapy
-Individual psychotherapy
-Vocational therapy

-40% remission-social recovery,60% deteriorated.
-Less than one year 30% full remission,30% social recovery &
30% will be long stay in mental hospital
-Bad prognosis:
flat affect, lack of initiative,depersonalization & derealization,
bad premorbid personality,gradual symptoms too high perso
nal aspiration,signs of hypochondriasis,persistent hallucination,
recovery more than one year, deep regression.
-Good prognosis:
acute,clear affective ..elements, clear anxiety or emotional
signs, cyclothymic premorbid personality, self-accused hallucination,
longer interval of remission.
-Robin & Guze :
Good :good premorbid personality,clear precitating factor,negative
family hystory or affective elements,clouding conciousness, acute
onset, no flatness of affect, paranoid symptoms.

PROGNOSIS-II (Kaplan & Sadocks)

To evaluate the prognosis it's better to look up the longitudinal history of illness
begins with the family hystory and at last how about the support system.
Features weighting towards good to poor pronosis in schizophrenia
-Good prognosis
-Family history of mood disorders
-Good premorbid social,sexual & work hystories
-Late onset
-Acute onset
-Obvious precipitating factors
-Mood disorder symptoms (especially depressive disorders)
-Positive symptoms
-Good support systems
-Poor prognosis
-Family history of schizoprenia
-History of perinatal trauma
-Young onset
-Poor premorbid social,sexual & works histories
-Single,divorced or widowed
-Insidious onset
-No precipitating factors
-Neurological signs & symptoms
-Withdrawn,autistic behavior
-Negative symptoms
-No remmission in 3 years
-Many relapses
-History of assaultiveness
-Poor support systems


*Schizophrenia and schizotypal --starting almost
*In schizophrenia:
-distortion of thought & perception
-hallucination & perception changes,
---confusion,elliptical & unclear thought,
-motility--interrupted & interpolation,
-thought insertion,
-inappropriate & blunted affect,
-ambivalency & desire -disorders (volition ):
-inertia,negativism,stupor catatonia,
- the course of illness:
-acute onset or gradual-silent,
-later becomes broader variation,
-not always chronic or become worse

Minimal one month at- least one of the following symptoms:
a.thought echo/insertion/withdrawl/broadcast,
b.delusion of control/influence-passivity,
c.comment/dialogue/discussion hallucinations or from the
organs of the body,
d.bizzare delusion
or at least two of the following symptoms:
e.persistent hallucination/delusion/overvalued ideas,
f.interrupted motility thought/insertion-incoherence/neologisme
g.catatonic behavior:excitement,posturing,mutism,negativism
flexibilitas cerea,stupor.
h.negative symptoms :apathy, paucity speech,blunting/
incongruity emotional response,resulting in social withdrawl/
lowering social performance and all of these causing:
i.a significant and consistent change in the overall quality of
some aspect of personal behavior manifest as loss of interest,
aimlessness,idleness,a self absorbed attitude and social

-prodormal phase/non psychotic:
-loss of interest in works,social activities and personal
appearance and hygiene together with generalized anxiety
and mild depression and preoccupation,before the psychotic
symptoms for some weeks/month
Pattern of course:
-episodic with progressive deterioration,
-episodic with stable deficit,
-episodic remittent,
-with incomplete remission or
-complete remission.
-periode of observation less then one year.
Criteria of time for residual schizophenia minimal 1 year and for
schizotypal disorder 2 years, if the psychotic phase not yet 1
month, the preliminary diagnosis is Acute Schizophrenic-like

Subtypes of schizophrenia
F 20.0 Paranoid schizophrenia
The general criteria for a diagnosis of schizopheni must be satisfied.In addition,
hallucinations and/or delusions must be prominent,and disturbances of affect,
volition and speech,and catatonic symptoms must be relatively inconspicious.
Delusions can be of almost any kind but delusions of control,influence,or passivity,
and persecutory belief of various kinds are the most characteristic.,
F20.1 Hebephrenic schizophrenia
A form of schizopohrenia in which affective changes are prominent,delusions and
hallucinatons fleeting and fragmentary,behaviour irresponsible and unpredictable,
and mannerisms common.The mood is shallow and inappropriate and often
accompanied by giggling or self-satisfied,self-absorbed smiling,or by a lofty
manner, grimaces, mannerisms,pranks,hypochondriacal complaints,and reiterated
phrases. Thought is disorganized and speech rambling and incoherent.There's a
tendency to remain solitary, and behaviour seems empty of purpose and feeling.
Usually starts between the age of 15 and 25 years and gendss to have a poor
prognosis because of the rapid development of negative symptoms,particularly
flattening of affect and loss of volition.

F20.2 Catatonic schizophrenia

Prominent psychomotor disturbances are essential and dominant features and may
alternate between extremes such as hyprkinesis ands stupor,or automatic obedience
and negativism.Constraineds attitude and postures maybe maintained for long
periods. Episodes of violent excitement maybe a striking feature of the condition.
F 20.3 Undifferentiated schizophrenia
Condition meeting the general dignostic criteria for schizophrenia,but not conforming
to any of the above subtypes,or exhibiting the features of more than one of them
without a clear of predominance of a particular set of diagnostic characteristic.
F 20.5 Residual schizophrenia
A chronic stage in the development of a schizophrenic disorders in which there has
been a clear progression from an early stage comprising one or more episodes of
exacerbation to a later stage.
F 20.6 Simple schizophrenia
Slowly progressive develpment of the characteristic negative symptoms of residual
Schizophrenia without any history of hallucinations,delusions or other manifestations
of earlier psychotic episode,and with significant changes in personal behaviour,
manifest as a marked loss of interesr,idleness,and social withdrawal.

F 25 Schizoaffective disorders
These are episodic disorders in which both affective and schizophrenic symptoms are
prominent within the same episode of illness,preferably simultanously,but at least
within a few days of each other.
F 25.0 Schizoaffective disorder,manic type
There must be a prominent elevation of mood,or a less obvious elevation of mood
combined with increased irritability or excitement.Within the same episode,at least one
and preferably two typically schizophrenic symptoms should be clearly present.
F 25.1 schizoaffective disorder,depressive type.
A disorder in which schizophrenic and depressive symptoms are both prominent in the
same episodes of ilness.Depression of mood is usually accompanied by several
characteristic depressive symptomsor behavioural abnormalities such as retardation ,
insomnia, lost of energy, appetite or weight reduction of normal interests,impairment
of concentration guilt,feelings of hopelessness,and suicidal thoughts.At the same time
or within the same episode,other more typically schizophrenic symptoms are present.
This subtype usually less florid and alarming than manic type,but they tends to last
longer and the prognosis is less favourable.Although the majority of patients recover
completely,some eventually develop a schizophrenic defect.
F 25.2 Schizoaffective disorder,mixed type
Disorders in which symptoms of schizophrenia coexist with those of a mixed bipolar
affective disorder.


A group of mental disorders with the
main disturbances in the affective
aspect, with or without psychotic
features,no signs of schizophrenia and
can exacerbate periodically.

Mood fluctuation:
ecstasy---------------exaltation-------------- hyperthymia
------ happy/cheerful-------------n o r m a l ------------- normo/euthymia
depression-------------------------- hypothymia

The term melancholia (Hippocrates) untill 19th

century meant mild /severe depression, after
Kraepelin era means only for depression in the
elderly. At the end of the 20th century means only
for severe depression, depression for the mild
and bipolar depression for cyclic depression.
Melancholia attack associated with hypoactivity/
motoric retardation, elation/ maniacal attack
associated with hyperactivity

According to Hippocrates the disorder

associated with affective aspect,while
Arateus said there's a relation between
melancholia and mania ; Freud claimed
that there's a fusion between ego and
super ego ; id and ego cyclic.
Abraham & Freud : in mourning condition,
loss of object because of death, in
melancholia there's internal/
identification ------introjection

Mostly endogenous ( 25x ----------> in sibling and 50%
in monozygotic twin
~ 2-36 in 100.000 population
~ 3x in high societies & professionals
~ women 2x men
~ 5-15% of psychotic patients in mental hospital
Precipitating factors:
Loss one of the valuable objects e.g:
-failures in interpersonal relationship,
-frustation associated with loyalty

The symptoms in the affective aspect,
thought process and behavioral
although pathological but more or less
is still harmonious and it's clearly apart
between manic & depression.

-rare hallucination (mostly flattery/praise)
-associations:-flight of ideas,logorrhoe-clangassociations
-thought contents : expansive hallucinations
non-systematic,wishfullfilling,sometimes persecutory
-hyperactivity ,singing,dancing,shouting, impolite,
irritable, lack of sleep and never being tired/exhausted,
attention easily changed, many plans but never
-mild condition:
-hypomania: mild type e.g: talk too much,busy,self
confidence, self pride, agressive,irritable,argumentative,
extravagance,more chronic,.becoming milder
-impression: overconfident but actually overdependent

-early onset 20-25 years, if younger will be worse
-more acute will be better
-more often excarcerbation tends to poor prognosis
-mixed with schizophrenic symptomsnot good
-without therapy the attack last about 6 months
-difficult to prevent excacerbation even with good drugs
-chronic condition rarely before 40 years

-affect : hypothymia,with pessimism,annoyed&gloomy
-association not smooth with hemmung & sperrung,
monosylable talked,sometimes no voices
-thought content: ideas of guilty feeling and sin,
hypochondriasis, self-accused and nihilistic delusions,
paranoid idea, hallucinations followed the affect until
suicidal thought,
-behavior:hypoactive sometimes until stupor,refuse to eat &
drink and resulting dehydration,
-sometimes homiside as an extention from the suicidal act &
it happened when the motoric retardation reduces but the
suicidal thoght still present,often in condition with anxiety
& positive family history.

-early onset 30-35 years
-more younger the prognosis will be worse
-if depression come firstly, it's uncertain will be back again,
-mostly more endogenusly, the prognosis will be worse,
-growing older the depression will be more often,
-without therapy the recovery needs 9 months,
-more acute will be better, more chronic become milder,
-more often means worse
-compared with mania this type tends to become chronic,
-hypochondriasis & severe nihilism with a lot of anxieties
means poor prognosis.


A group of affect disorders with elation or depression with or
without anxiety accompanied with changes in activity.
The variation of the diorders:
-single or multiple episode
-level of symptoms severity:
-psychotic mania---mania without pschotic symptoms---hypomania ;
-mild &---middle depression (with or without somatic
symptoms)--severe with or without psychotic symptoms.
-mild condition but relatively longer & persistant.

F30 Manic episode include hypomania
F31 Bipolar affective disorder,with recent
episode manic/depression /mixed
F32 Depressive episode
F33 Reccurent depressive disorder
F34 Persistant affective disorders include
cyclothymia and dysthymia
F38 Other mood (affective) disorders.
F39 Unspecified mood (affective) disorders

In hypomania:
-milder than mania,
-at least for several days
-intensity more then cyclothymia
Manic episode:
-acute, duration 1-2 weeks untill 4-5 months
Depressive episode:
-longer,duration about 2weeks untill 6 months rarely
more then 1 year except in old age
-Often begins with stress but not always, specifically:
full recovery between episode.
-for bipolar minimally there should be once for other
affective episode.

Bipolar Disorder Is

Subsyndromal Mania


Subsyndromal Depression

Depressive episode -PPDGJ III/ICD X

-Main symptoms:-decrease affect/depressed mood
-loss of interest/enjoyment
-lack of energy
-Other symptoms:-reduced attention/concentration
-reduced self esteem & self confidence
-ideas of guilt and unworthyness
-bleak and pessimistic view of the future
-ideas of acts of self harm or suicide
-disturbed sleep
-diminished appetite
-The lowered mood varies,often unresponsive to
circumtances sometimes there's diurnal variation,severe
symptoms maybe shorter than 2 weeks.

-For diagnostic minimal 2 main symptoms ,severity

between 2-4 additional symptoms with mild till severe
impairment & psychotic if there're delusions,
hallucintions (auditoric/ olfactoric) or depressive stupor.
-Recurrent depression at least had more than 2 episodes,
more infrequent than bipolar attacks.
-In cyclothymia the specific characteristics is persistent
instability between mild depressive periode and
-In dysthymia,the depression very long but mild, minimal
can be several years.


A group of severe mental diorders with the main symptoms
is a variety of delusions, often systematic with or without
The psychotic symptoms often very clear & sometimes
only delusions which is dominant.
Since Hippocrates,paranoia means "sanity",used again by
Vogel, and more confirmed by Kahlbaum (1863).
Kraepelin: introduce the term paraphrenia and there're 4
type: systematic,expansive,confabulative and fantastic.
Freud: paraphrenia is identically the same as paranoid

In PPDGJ II these disorders includes:

-shared paranoid disorders,
-unspecified paranoid disorders
-F22 Persistent delusional diorders
-F 23.3 Other acute predominantly delusional
psychotic disorder.
-F 24 Induced delusional disorder

Prevalence (USA) 0.025-0.03% ( Schizophrenia 0.1 %
and affective disorders 0.5%).Women twice than men
and usually single and suspected with homosexual
orientation and chronic prejudice.

Age:average 40 years,when the delusions cannot be

tolerated anymore, the agression drive will invite
counter agression from the environment and so
make it easier to develope delusion of persecution,
nihilistic etc.,resulting abandoned by friends, feeling
isolated/unwelcome and inferior, finally become
more paranoid.

-Psychogenic cause: frustated ambition drive
-Freud :homosexual fixation
-sadistic experiences during early childhood
( anal sadistic phase)
-Genuine paranoid rarely seen,usually an extension of
paranoid premorbid personality.
-more often in the form of paranoid reaction,
-the defence mechanism which is used: denial &
-Heriditary / constitutional e.g:
-low threshold for frustation,
-rigid in relationship,
-hypersensitivity etc.

The main symptoms:delusions,logic,sistimatic,complex,sometimes
looks like isolated /apart from the personality,so the personality seems
intact, and disturbed when the delusions being touch.
-Persecuted delusions:feels being hatred- by relatives,want to be
unmistakeable, the misintepretation & misunderstanding resulting in
persecuted delusions.
-Delusion of reference if there's a feeling that someone is talking or
commenting obout him/her
-Litygious type: feeling of being treated unfair,feeling of being right and
-Exaltase type:delusions of grandeur,megalomania,often appear long
time after persecuted delusions, often feels as Gods mission
-Erotic type:feeling the celebrities fall in love with him/her.
Often appear as suicidal homocidal action.


1877: Laseque & Falret: induced psychosis with symptom
of delusions,in close relatives, the induced person
which is submissive,suggestibel, dependent and
emotionally depends on the first.
The used defence mchanism is identification.

Rarely genuine,often mixed wirth melancholia
Premorbid full of defence mechanism projection,
inferior,critical,tends to blame others,jealous,
cannot forgive,suspicious.
Symptoms:-organized persecutory delusion,
annoyed, feeling of hostility.
Prognosis:-worse than involutional melancholia

Premorbid usually paranoid personality e.g

blame on others easily,many prejudice,
uneasy to confess wrong,often irritable
easily hurt, angry, egocentric and easily
paranoid/ suspicious.
Not so good in genuine paranoia with
paranoid personality back ground which
begins gradually or if there's a picture of
schizophrenic symptoms because of rarely
full remission.


-Having uncertain relation with schizophrenia
-Specifically:persistent single/systematic delusions, sometimes
all life ---long.
-Often delusions of persecutory,hypochondriac,grandiose or
which is related with court,jealousy,abormal body,feels
that the body has bad smell or homosexual.
-Depression symptoms can be found intermittently.
-Maybe there're olfactoric and tactil hallucinatios
-Auditoric hallucination appears temporaly & generally in
old age.
-Usually in midslife age ,except in abnormal body delusion
which often in young age
-Often related with environtmental situation,persecutrory
delusion frequently in minority group.
-Apart from the behavior & attitude related with delusions, the
affect, talking & behaviour still normal.

Other persistent delusional disorder

-Delusional disorder with persistent
hallucination or schizophrenic
symptoms which not enough for
schizophrenic criteria and minimally 3
months duration.
-Includes here: delusional dysmorphobia
& involutional paranoid state.


Includes here are depressive type psychosis
or excitation, reactive confusional state,
acute or psychogenic paranoid disorders,
brief reactive psychosis and unspecified
Usually there's a real stressor in
interpersonal relatioship problems or
environmental problems which are very
stressfull and generally last during 2weeks
until 6 months and the prognosis usually
good enough


-phenothiazine: -chlorpromazine: tablet 25mg; 100mg
-levomepromazine: tablet 25 mg; 100 mg
-perphenazine : tablet 4 mg; 8 mg
-trifluoperazine: tablet 5 mg
-thioridazine: 10 mg; 100 mg
-haloperidol: tablet 0,5mg;1,5mg;2mg;5mg
-pimozide : tablet 2mg; 4 mg


-sulpiride :tablet 50mg; 200mg
-clozapine:tablet 25mg; 100mg
-olanzapine:tablet 5mg; 10 mg
-quetiapine: tablet 25mg; 100mg; 200mg
-zotepine:tablet 25mg; 50mg
-aripiprazole; tablet 10mg; 15 mg
-risperidone: tablet 1mg; 2mg; 3 mg
-paliperidone : kapsul 3mg; 6 mg ;9mg

1.Golongan ikatan trisiklik
-amitriptyline : tablet 25 mg
-imipramine: tablet 10 mg; 25 mg
-tianeptine: tablet 12,5 mg
2.Golongan ikatan tetrasiklik
-maprotiline : tablet 25 mg; 50mg
-mianserine: tablet 10 mg; 30 mg
-amoxapine: tablet 100 mg
3.Golongan Mono Amine Oxidase Inhibitor (MAOI)Reversible
-moclobemide: 150 mg
4.Golongan Selective Serotonin Reuptake Inhibitor (SSRI)
-sertraline: tablet 50 mg
-fluoxetine: tablet 20 mg
-paroxetine : tablet 20 mg
-fluvoxamine: tablet 50 mg
-citalopram : tablet 20 mg
5.Golongan antidepresan atipikal
-mirtazapine: tablet 15mg; 30mg; 45 mg
-duloxetine: tablet 60mg; 120mg
-venlafaxine Hcl: tablet 75mg; 150mg; 225mg

1.Mania akut:
-haloperidol:tab 0,5mg; 1,5mg; 2mg; 5mg
-carbamazepine: tablet 200mg
-valproic: tablet 200mg
-lithium carbonate: tablet 200 mg
2.Profilaksis: -lithium carbonate tablet 200mg


There are 3 aspects of the personality, wether psychotic or not,its
depends on the dysfuntion/disorder/disturbance of these aspect.
Affective /Stimmung
-afeftive state:normo/euthymia,hyperthymia,
hypothymia, poikilothymia,disthymia,
blunted/flat/inappriate affect
-emotional state
Thought /Denken
-intellectual function:memory,concentration,
orientation,discriminative judgement/insight,
intelligency level,dementia etc
-sensation & perception:illusion,hallucination
-thought process:-psychomotility,quality
-associations,content and form etc
Behaviour and instinctual drive/ Handlung
-abulia/hypobulia ,stupor,raptus,impulsivity,sexual
deviation, vagabondage,pyromania,mannerism,
mutisme,autisme etc