SCHIZOPHRENIA SPECTRUM

and
OTHER PSYCHOTIC DISORDERS

DSM 5
 DSM 5 Classification
• Schizophrenia
• Other Psychotic Disorders
• Schizotypal Personality Disorder
SCHIZOPHRENIA
Outline
• History
 Epidemiology (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
• 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
• (+) Hx of Prenatal exposure to viruses, toxins or
malnutrition
• (+) Hx of taking mind-altering (psychoactive or
psychotropic) drugs during teen years and
young adulthood - Mayo Clinic
• Increased immune system activation (from
inflammation or autoimmune diseases}
• Older age of the father
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-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 must be (1), (2),or (3)

 DSM-5 specifiers
• Course specifiers (after 1 yr)
– First episode, currently in…
• Acute episode
• Partial remission
• Full remission
– Multiple episodes, currently in…
– Continuous
• 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
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
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
• - w/o
• - insidious
• - poor
• Single/divorced/widowed
• Withdrawn/autistic behavior
• Fam hx of schizophrenia
• -poor
• Negative symptoms
• Neurological S/Sx
• Hx of perinatal trauma
• No remissions/ many relapses
• Hx of violent behavior
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
• Diagnosis
• Stabilization of meds
• Safety (suicidal/homicidal ideation)
• Grossly disorganized/inappropriate behavior
 Schizophrenia in summary
• 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
THANK YOU