SCHIZOPHRENIA SPECTRUM

and
OTHER PSYCHOTIC DISORDERS

DSM 5
 outline
• Psychosis / psychotic disorder
– Definition
– Clinical manifestations
– Differential diagnosis
• Schizophrenia
– Epidemiology
– Etiology
– Clinical features
– Diagnosis. Treatment, and Prognosis
• Other psychotic disorders
 Psychosis
• A break from reality involving delusions,
perceptual disturbances (hallucinations)
and/or disordered thinking (disorganized
speech)
 Delusions
• Fixed, false beliefs that cannot be altered by
rational arguments and cannot be accounted for by
the patient’s cultural background

• Types:
– Paranoid delusion: of persecution/ of jealousy
– Delusions of grandeur
– Delusions of guilt
– Ideas of reference
– Thought broadcasting
 Perceptual disturbances
• Hallucinations
– Auditory : most commonly exhibited by
schizophrenia patients
– Visual : commonly seen with drug intoxication
– Olfactory : usually an aura in epilepsy
– Tactile: usually due to drug abuse or alcohol
withdrawal
• Illusions
 Disorganized speech
• thought process: manner in which the patient
links ideas and words together
– Tangentiality
– Circumstantiality
– Word salad and neologisms
– Loosening of associations
– Thought blocking
– Perseveration
– Loss of ego boundaries
 Differential diagnosis of psychosis
• Secondary to a medical condition*
• Substance-induced*
• Delirium/dementia*

• Bipolar disorder
• Major depressive disorder with psychotic features

• Brief psychotic disorder

• Schizophrenia
• Schizophreniform disorder
• Schizoaffective disorder
• Delusional disorder
 DSM 5 Classification
• Schizophrenia
• Other Psychotic Disorders
• Schizotypal Personality Disorder*
Schizophrenia spectrum disorder
SCHIZOPHRENIA
Outline
• History
 Epidemiology (prevalence/risk factors)
• Etiology
 Diagnosis (criteria and classification)
 Clinical features
 Differential Diagnosis
• Course and Prognosis
• Treatment
History
• Benedict Morel (1809-1873) used the term demence
precoce for a deteriorating illness that began in
adolescence

• Emil Kraepelin (1856-1926) distinguished dementia precox

from patients with manic-depressive psychosis and those
with paranoia

• Eugene Bleuler (1857-1939) used the term schizophrenia;

identified specific fundamental(primary) and accessory
(secondary) symptoms
Epidemiology
• Lifetime prevalence : 1% (equal in M and F)
• Earlier onset (10-25y.o.) in M; bimodal in F
• Biological relatives have 10x greater risk

• Birth season : Jan-April (N); July-Sept (S)

• Maternal viral infection (influenza)
• High cannabis use increases risk for Schiz 6X
• Increased paternal age
epidemiology
• Population density
• 15-45% of homeless (USA); 50% of MH beds
Risks:
• Patients have higher mortality rate
• 80% have concurrent medical illness
• Lifetime prevalence of substance use is > 50%
Schizophrenia and Substance use

• Lifetime prevalence of alcohol use = 40%

– Abuse is associated with poorer function (except
with nicotine)
• Nicotine dependence in up to 90%
 Increased mortality
 May decrease positive symptoms (hallucinations)
 Risk factors
• Family history of schizophrenia
• Prenatal exposure to viruses, toxins or malnutrition
• Increased immune system activation (from
inflammation or autoimmune diseases}
• Older age of the father
• Taking mind-altering (psychoactive or psychotropic)
drugs during teen years and young adulthood
– Mayo Clinic
Etiology
• Genetic : 50% concordance rate for monozygotic
twins
• Biochemical factors:
high dopaminergic activity* ; glutamate
• Neuropathology :
– enlarged ventricles, reduced symmetry, abnormalities in
prefrontal cortex, thalamus, basal ganglia and cerebellum
– Neural circuits disorder
– Abnormal electrophysiology : sound sensitivity
– Abnormal eye movements
– Psychoneuro immunology / endocrinology
Etiology
• Biological Factors
• Psychoanalytic theories
– Developmental fixations (Freud)
– Disturbance in interpersonal relations (Sullivan)
• Learning theories
• Family dynamics
– Double bind
– Skewed families
– High levels of expressed emotion
 Diagnosis (DSM-IV-TR)
A. Characteristic symptoms
B. Social/Occupational dysfunction
C. Duration
D. Schizoaffective and mood disorder exclusion
E. Substance/gen. med. condition exclusion
F. Relationship to a pervasive devt.al disorder
specifiers
Diagnosis (DSM-5 Diagnostic Criteria)

2 or more of the following must be present during a

1-month period (or less if treated)*
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms

*at least one of these 2 must be (1), (2),or (3)

 Two (2) types of symptoms
• Positive symptoms
– hallucinations, delusions, bizarre behavior, thought
disorder

• Negative symptoms*
blunted affect anhedonia
apathy inattention
(5 A’s : anhedonia, alogia, affect, avolition, attention)
*considered by some to be at the “core” of the disorder
 Three (3) phases
1. PRODROMAL – decline in functioning that
precedes the first psychotic episode
(social withdrawal, irritability, somatic complaints,
increased interest in religion/the occult)
2. PSYCHOTIC
3. RESIDUAL – occurs between episodes of
psychosis (marked by flat affect, social withdrawal,
odd thinking)
Clinical Features
• No clinical sign or symptom is pathognomonic
• Symptoms change with time
• The ff. must be taken into account
– Educational level
– Intellectual ability
– Cultural/subcultural membership

Patient’s history is essential for the diagnosis.

Clinical Features
• Premorbid signs and symptoms (prodrome)
– Schizoid/schizotypal personality
• Quiet, introverted, passive
• Few friends as child
• No close friends/dates as adolescent
• Avoid team sports and social activities
• Enjoy movies/TV, music, computer games
– Somatic symptoms
– Interest in abstract ideas/philosophy/religion
 Mental Status Examination
A. Appearance
B. Speech
C. Mood and affect
D. Thinking and perception
E. Sensorium and cognition*
F. Impulsivity
G. Insight and Judgment
 Sensorium and cognition
• Consciousness
• Orientation
 Memory
 Concentration and attention
• Reading and writing
 Visuospatial ability
 Abstract thought
 Information and intelligence
Clinical Features
• Appearance: range from 2 extremes
• Reduced to overly active, inappropriate emotions;
flat/blunted affect
• Hallucinations : auditory and visual
• Illusions
• Disorders of thought (may be core symptoms)
– Thought content (delusions)
– Form of thought (looseness of assoc., tangentiality)
– Thought process (flight of ideas, thought blocking)
Clinical Features
• Poor impulse control (risk factors)
 Violent behavior (persecutory delusions, previous
history of violence, neurological deficits)
 Suicide (presence of major depressive episode,
command hallucinations, drug abuse)
 Homicide (hx of violent behavior, violent delusions)
• Cognitive impairment* (attention, executive
function, working memory and episodic memory)
• Poor insight  poor compliance w/ tx
Symptoms in teenagers
• early symptoms are common for typical
development during teen years:

• Withdrawal from friends and family

• A drop in performance at school
• Trouble sleeping
• Irritability or depressed mood
• Lack of motivation

• Less likely to have delusions

• More likely to have visual hallucinations*
Clinical features
Comorbidity (complications)
• Neurological S/Sx
• Elevated blink rate

• HIV
• COPD
• Effects of antipsychotic medications
– Obesity
– Type II DM
– Cardiovascular disease
 Psychometric Tests
1. Intelligence testing
Wechsler Adult Intelligence Scale (WAIS)
2. Personality tests
Minnesota Multiphasic Personality Inventor(MMPI)
Rorschach Test
Thematic Apperception Test (TAT)
Sentence Completion Test (SCT); Word-Association technique
Draw-a-Person Test
3. Neuropsychiatric tests
Neuropsychological tests
• Wisconsin Card Sorting Test
• Wechsler memory Scale
• Benton visual Retention Test
• Bender Visual Motor Gestalt Test
• Facial Recognition Test
• Boston diagnostic aphasia Examination
 MMSE
 Luria-Nebraska Neuropsychological Battery
 Halstead-Reitan Battery of Neuropsychological tests
 DSM-5 specifiers
• Course specifiers (after 1 yr)
– First episode, currently in…
• Acute episode
• Partial remission
• Full remission
– Multiple episodes, currently in…
– Continuous
• Specify if w/ or w/o catatonia
• Current severity
Subtypes (DSM-IV-TR)
• Paranoid
– Tense, suspicious, guarded, reserved; older
• Disorganized
– Marked regression, pronounced thought disorder
• Catatonic
– Stupor, rigidity, negativism, mutism
• Undiferrentiated
• Residual
– Absence of complete set of active symptoms
 Other subtypes
• Acute Delusional Psychosis
• Latent Schizophrenia
• Paraphrenia
• Pseudo-neurotic Schiz (Borderline Personality D)
• Simple Schizophrenia (Simple Deteriorative D)
• Post-psychotic Depressive Disorder of Schiz.
• Early-onset Schizophrenia
• Late-onset Schizophrenia
• Deficit Schizophrenia
Differential Diagnosis
• Secondary Psychotic Disorders
• Other Psychotic Disorders
• Mood Disorders
• Personality Disorders
• Malingering and Factitious Disorders
Course and Prognosis
• Prodrome (1 yr)  psychotic symptoms
• Remissions and exacerbations
• Pattern of first 5 yrs is predictive of course
• No return to baseline functioning
• Lifelong vulnerability to stress

• Not always deteriorating : 20-30% are able to lead

normal lives; >50% w/ poor outcome
• Prognostic factors
 Prognostic factors
GOOD prognosis
• Late onset
• w/ precipitating factors
• Acute onset
• Good premorbid history
• Married
• With mood disorder sx
• Family hx of mood disorders
• Good support systems
• Positive symptoms
POOR prognosis
• Early onset
• w/o precipitating factors
• Insidious onset
• Poor premorbid history
• Single/divorced/widowed
• Withdrawn/autistic behavior
• Fam hx of schizophrenia
• Poor support systems
• Negative symptoms
• Neurological S/Sx
• Hx of perinatal trauma
• No remissions/ many relapses
• Hx of violent behavior
PROGNOSTIC FACTOR GOOD PROGNOSIS POOR PROGNOSIS

AGE OF ONSET LATE EARLY

PRECIPITATING FACTORS PRESENT ABSENT

ONSET OF SYMPTOMS ACUTE INSIDIOUS

PREMORBID HISTORY GOOD POOR

CIVIL STATUS MARRIED SINGLE

COMORBIDITY MOOD DISORDER WITHDRAWN/AUTISTIC

SYMPTOMS
FAMILY HISTORY MOOD DISORDER SCHIZOPHRENIA

SUPPORT SYSTEM GOOD POOR

 PROGNOSTIC GOOD PROGNOSIS BAD PROGNOSIS
FACTORS
PREDOMINANT POSITIVE SYMPTOMS NEGATIVE SYMPTOMS and
SYMPTOMS NEUROLOGICAL S/SX
HISTORY UNEVENTFUL (+) HX OF PERINATAL TRAUMA
(+) HX OF VIOLENT BEHAVIOR
REMISSIONS PRESENT NONE, OR IF PRESENT, WITH MANY
RELAPSES
Treatment
• Antipsychotics
– 1st gen : dopamine receptor antagonists (DRAs)
– 2nd gen: serotonin dopamine antagonists (SDAs)
• Psychosocial interventions
– Psychotherapy: group/individual/cognitive behavioral
– Social skills training
– Assertive community therapy (ACT)
– Art therapy
• Hospitalization
 Indications for hospitalization
1. Diagnosis
2. Stabilization of meds
3. Safety (suicidal/homicidal ideation)
4. Grossly disorganized/inappropriate behavior
 Schizophrenia
• A clinical syndrome that involves various
aspects of behavior  psychotic symptoms
• A brain disorder
• A grp of disorders with different etiologies ?
• Prevalence of 1%
• Chronic, often deteriorating and lifelong
• Diagnosis is based on careful History and
MSE
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