UNIT FOUR: PSYCHOTIC DISORDERS

Brief psychotic disorder-1 day to 1 month history of

illness
Schizophreniform disorder-1 month but <6 month
history
Schizophrenia --->6 months history of psychotic illness
Schizoaffective disorder----both psychotic and
mood symptoms
Delusional disorder----non-bizarre delusion >1
month history
Psychotic disorder secondary to substance use

Psychotic disorder secondary to General Medical

Condition (GMC)
 Schizophernia

History of schizophrenia
Etiology
Symptoms dimension in schizophrenia

Sub-types of schizophrenia

DSM IV criterion for diagnosis of

schizophrenia
Management
 Schizophrenia

Eugen Bleuler, a Swiss psychiatrist, coined the term Schizophrenia

‘Schiz’-broken; ‘Phrenos’: -soul or heart  Splitting of the mind.

Schizophrenia is Psychotic disorder.

External behavior of schizophrenic pts seems bizarre to observers

Internal mental experiences are incomprehensible and frightening to the

patient.
Schizophrenia is a clinical syndrome of variable,
but profoundly disruptive, psychopathology that
involves cognition, emotion, perception, and other
aspects of behavior.
The diagnosis of schizophrenia is based entirely
on the psychiatric history and mental status
examination.
There is no laboratory test for schizophrenia.
 Etiology
A. Stress diathesis model: A person may
have a specific vulnerability (diathesis) that
when acted on by a stressful influence,
allows the symptoms of schizophrenia to
develop.
Stressful influence includes:

Infection

Stressful family environment

Death of close relatives

Substance abuse, etc

 B. Genetics
Prevalence in General population = 1%
Non twin siblings of schizophrenia patient = 8%
Child with one parent with schizophrenia = 12%

Di zygotic twin of a schizophrenia patient = 12%

Child with two parent with schizophrenia = 40%
Mono zygotic twin of schizophrenia patient = 47%
 C. Biochemical Factors
 Dopamine Hypothesis:

 The dopamine hypothesis of schizophrenia posits that

schizophrenia results from too much dopaminergic

activity in the mesolimbic pathway.

 The theory evolved from two observations:

 The efficacy and the potency of many antipsychotic drugs

(i.e., the dopamine receptor antagonists )

 Drugs that increase dopaminergic activity, notably

cocaine and amphetamine, are psychotomimetic.

 Up to 75% of patients with schizophrenia have

increased signs and symptoms of their psychosis

upon challenge with moderate doses of

methylphenidate or amphetamine or other

dopamine-like compounds.
 FOUR DOPAMINE PATHWAYS IN THE BRAIN

(i) Nigrostrial Pathway: Substantia Nigra to Basal

Ganglia (movement)
(ii) Mesolimbic Pathway: Venteral Tegmental Area
(VTA) of the Brainstem to Limbic Systems of the
Brain (Positive schizophrenia symptoms)
(iii) Mesocortical Pathway: VTA to Frontal
Cortex (Negative &Cognitive
schizophrenia symptoms)
(iv) Tuberoinfundibular Pathway:
Hypothalamus to Anterior Pituitary
Gland (Prolactin secretion)
Five Symptoms dimension in schizophrenia

1. Positive symptoms of
Schizophrenia
Delusion
Hallucination
Disorganized Speech and Behavior
Catatonic Behavior
 2. Negative symptoms of Schizophrenia
4 A’s

Asocialia

Avolition

Anhedonia

Affective flattening
Negative symptoms are:

 More refractory to treatment

Atypical antipsychotics better than

typical ones
3. Cognitive symptoms of Schizophrenia

Impaired attention

Impaired information processing

Impaired learning

Impaired thought

Impaired memory
4. Aggressive symptoms of Schizophrenia

Hostility

Verbal abusiveness

Physical Assault
Self-injurious behavior including suicide

Arson/property damage

Impulsiveness
 5. Depressive/Anxious symptoms of Schizophrenia

• Depressed mood

• Anxious mood
• Guilt
• Tension
• Irritability
• Depression develops in 25-50% of individuals with
schizophrenia and can be associated with suicidal
 Sub-Types of Schizophrenia

1. Paranoid Subtype

 Pre-occupation with one or more delusions of

persecutions or grandeur

 Frequent auditory hallucinations

First episode of illness at an older age

Show less regressions of their mental

faculties, emotional responses and behaviors

than the other types do. 

Comparing to other sub-types paranoid type

show better outcome

 2. Disorganized Subtype

Disorganized thought, speech, and behaviour

Affective flattening
Marked regression to primitive /childhood
state

Onset before the age of 25

Poor outcome
 3. Catatonic Subtype
Marked disturbance of motor activity that is apparently
purposeless and not influenced by external stimuli.

Motoric immobility evidenced by stupor, waxy flexibility

Negativism, rigidity, excitement
Peculiarities of voluntary movement e.g. mannerisms
Echolalia or echopraxia
 Two of the above symptoms are required.
 4. Undifferentiated Subtype

Criterion A symptoms are present, but the

criteria are not met for the paranoid,
disorganized, or catatonic behavior.
5. Residual Subtype
Presence of continuing evidence of
schizophrenia symptoms in the absence of
active symptoms.
Presence of Emotional blunting, social
withdrawal, eccentric behavior, odd beliefs.
 DSM IV criterion for diagnosis of Schizophrenia:

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)
Delusion

Hallucination
Disorganised speech
Grossly disorganized or catatonic behaviour

Negative symptoms
NB: 0nly one criterion A symptom is
required if:
Delusions are bizarre or
Hallucination running commentary type-
two/more voice conversing with each other.
B. Social or occupational
dysfunction/impairment
C. Duration: Continuous sign of disturbance for 6
months; one month of active symptoms.

D. Exclusion: Schizoaffective and mood disorder

E. Exclusion: Substance/General Medical Condition

F. Relationship to a pervasive developmental

disorder.
 Management
Therapeutic principle

Define the target symptoms to be treated

An antipsychotic that has worked well in the past for

a patient may be used
The minimum length of an antipsychotic trial is 4-6
weeks at adequate dosages.
If trial is unsuccessful a different antipsychotic
drug, usually from different class can be tried.
In Treatment resistance cases, combination of
antipsychotics with other drugs e.g.
carbamazepine, lithium, valproate is
recommended.
Maintain on the lowest possible effective
dosage of medication.
 Pharmacological therapy
Typical antipsychotics
 Low potency : Chlorpromazine, Thioridazine

 Medium potency: Stelazine, Perphenazine

 High potency: Haloperidol, Fluphenazine
deconate/Modicate injection
Atypical antipsychotics

e.g. Clozapine, Risperidone, Olanzapine

Similar efficacy with typical ones except for
side effect profile.
Clozapine is effective in severely ill, refractory
cases & pts With Tardive Dyskinesia/TD/.
Associated with Agranulcytosis in 1-2%.

Weekly monitoring of CBC is required.

 Duration of therapy
1st episode- maintenance therapy for 1-2 years
Multi-episode- maintenance therapy for 5 years
Several severe episodes ,suicidality, violence,
aggression may require indefinite maintenance
therapy.
Psychological therapy

• Cognitive behavioural therapy (CBT) for

delusions and hallucinations
• Family therapy (expressed emotions)

Social support

• Refer to Support groups (e.g. National

Schizophrenia Fellowship)
 Other Psychotic disorders
1. Brief psychotic disorder a psychotic condition that involves the
sudden onset of psychotic symptoms, which lasts 1 day or more
but less than 1 month.
Diagnosis
 based primarily on the duration of the symptoms.
 not associated with a mood disorder, a substance related disorder,
or a psychotic disorder caused by a general medical condition.

35
 Diagnosis cont…
Presence of one or more of the following symptoms
– delusions
– hallucinations
– disorganized speech (e.g., frequent derailment or
incoherence)
– grossly disorganized or catatonic behavior
 Duration of the disturbance is at least 1 day but less
than 1 month, with eventual full return to premorbid
level of functioning.
36
Specify if:
 With marked stressor(s) (brief reactive psychosis): If
symptoms occur in response to events that, singly or
together, would be markedly stressful to almost anyone
in similar circumstances in the individual's culture.
 Without marked stressor(s): If symptoms do not
occur in response to events that, singly or together,
would be markedly stressful to almost anyone in
similar circum­stances in the individual's culture.
 With postpartum onset: If onset is during pregnancy
or within 4 weeks postpartum.

37
 Treatment

Pharmacotherapy
 Antipsychotic drugs and the benzodiazepines.
 When an antipsychotic drug is choosen, a high potency such as
haloperidol or a serotonin-dopamine agonist such as
ziprasadone.
 Benzodiazepines can be used in the short-term.
Psychotherapy

 Although hospitalization and pharmacotherapy are likely to

control short-term situations, Exploration and development of
coping strategies are the major topics in psychotherapy.

38
 2. Schizophreniform Disorder

 Similar to schizophrenia, except that its symptoms last at

least 1 month but less than 6 months.
 Patients return to their baseline functioning once the
disorder has resolved.
 Most common in adolescents and young adults and is less
than half as common as schizophrenia.

39
 Schizophreniform disorder cont…
Diagnosis
 Met the criteria for schzophrenia
 Duration greater than 1 month but less than 6 months.
 Patients return to base line functioning with in 3-6 month
course of antipsychotic treatment.
Treatment
 Hospitalization often necessary, allows effective assessment,
treatment, and supervision of a patient's behavior.
 Respond to antipsychotic much more rapidly than patients
with schizophrenia.
40
Specify if:
With good prognostic features: This specifier requires
the presence of at least two of the following features:
 onset of prominent psychotic symptoms within 4
weeks of the first noticeable change in usual behavior
or functioning;
 confusion or perplexity;
 good premorbid social and occupational functioning;
 absence of blunted or flat affect.

41
 Without good prognostic features:
This specifier is applied if two or more of the above
features have not been present.

42
 3. Schizoaffective Disorder
 has features of both schizophrenia and mood disorders
 Diagnosis
 not always easy or even possible to diagnose
 An uninterrupted period of illness during which, at some
time, there is either a major depressive episode, a manic
episode, or a mixed episode concurrent with symptoms
that meet Criterion A for schizophrenia.

43
 Diagnosis cont…
• There should be Depressed mood to diagnose depression in
patients with this illness
• There have been delusions or hallucinations for at least 2
weeks in the absence of prominent mood symptoms.
• mood episode are present for a substantial proportion of total
duration
Specify bipolar or depressive type
44
 Schizoaffective d/r cont…
Treatment
• Mood stabilizers are a mainstay of treatment.
Initially high to middle therapeutic dose and
tapper for maintenance Rx
• Possible to combine with antipsychotics

45
 4. Delusional Disorder
 Delusional disorder is characterized by at least 1 month of
delusions but no other psychotic symptoms.
Risk Factors Associated with Delusional Disorder
• Advanced age
• Sensory impairment or isolation
• Family history
• Social isolation
• Personality features (e.g., unusual interpersonal sensitivity)
• Recent immigration
46
 Delusional d/r cont…
Diagnosis
 Patients are usually well groomed and well dressed,
without evidence of gross disintegration of personality,
yet they may seem eccentric, odd, suspicious, or hostile.
 Quite normal MSE is most remarkable finding

Criterion for schizophrenia has never been met.

 functioning is not markedly impaired and behavior is not
obviously odd or bizarre. 47
 Delusional d/r cont…
Treatment
 Delusional disorder was generally regarded as
resistant to treatment
 Management focus on relieving the impact of delusion
 Antipsychotics for severely agitated patients guided by
previous response, start with low dose and increase
 At least 6 weeks trial to switch to another class of drug
Psychotherapy
Establish trusting relationship
Individual psychotherapy is effective
48
 Substance/medical conditions induced
psychotic disorders
 Psychotic disorders may be induced by another
condition.
 In substance/medication ­induced psychotic disorder, the
psychotic symptoms are judged to be a physiological
con­sequence of a drug of abuse, a medication, or toxin
exposure and cease after removal of the agent.
 In psychotic disorder due to another medical condition,
the psychotic symptoms are judged to be a direct
physiological consequence of another medical
condition.

49
Thanks !!!