Schizophreniform Disorder

and Other Thought

Disorders
Alawad, Shayna M.
De Guzman, Jastine D.
Legaspi, John Clarence R.
Pilla, John Lemuel C.
Preceptorials in Psychiatry
Outline
Case Presentation (Jastine)
Definition of Thought Disorders (Jastine)
Neurotic vs Psychotic Patients
List of Psychotic Disorders
● Schizophrenia
● Schizoaffective
● Delusional Disorder
● Brief Psychotic Disorder
● Psychotic Disorder not otherwise specified
● Psychotic Disorder DUE TO GENERAL MEDICAL CONDITION AND SUBSTANCE INDUCED
PSYCHOTIC DISORDER
Clinical Features and Diagnosis of Psychotic/Thought Disorders (Lem and Jo)
Phases and Management of Schizophrenia (Shayna)
 General Data
❏ JS ❏ Unemployed
❏ 23-year-old ❏ Born on Oct 10, 1996
❏ Male ❏ In Calamba, Laguna
❏ Filipino ❏ Currently resides in Molino, Cavite
❏ Single
❏ Consulted for the first time at
❏ Practicing Dating Daan
CCMH-OPD on Oct 18, 2019
❏ Right-handed
❏ Accompanied by parents
❏ Speaks Filipino
❏ High school graduate
 Chief Complaint

Patient: “nababalisa”
Relative: “nababalisa” “nagwawala”
 Duration
Onset of recent symptoms:
2 days prior to consult (Oct 16, 2018)
3 days
Premorbid Personality and Level of
Functioning
According to the relatives, the patient was
● Usually happy
● Shy but friendly, maintains a close group of friends
● Not usually in conflict
● Generous and helpful to his family
● Showed concern and expressed compassion to other people

● Not studying and unemployed

● Quit his job because of workplace conflicts
● Active in sports such as basketball and biking
 History of Present Illness
Two months prior to consult,
According to the relatives,
● Patient became more religious
● Gave religious advice to relatives
● Described as “parang pastor”
● No sleep or appetite disturbance
● No change in functioning
● Dismissed by family as normal
● Did not seek consult
 History of Present Illness
One week prior to consult,
According to the relative,
● Patient was held up with a knife in Baclaran
● Patient came home troubled (“balisa”) and ”traumatized”
● Expressing fear that the criminal will come after him
● Patient experienced sleep disturbance
 History of Present Illness
Two days prior to consult,
According to the relative,
● Patient went home complaining of feeling week after he was
made to drink an “energy drink” by his friends
● Patient was restless
● Reported becoming more religious
● Patient was restless and shouting, complaining of seeing and
hearing “demons”
● Patient had trouble sleeping
 History of Present Illness
One day prior to consult,
According to the relative,
● Patient continued to be restless
● Patient became agitated and violent
● Patient was accompanied to seek consult at a general
practitioner
● Prescribed with “antihistamine” to calm him down, no relief
● Patient had trouble sleeping
 History of Present Illness
Five hours prior to consult,
According to the mother,
● Patient became agitated and violent
● Shouted about demons
● Prompted to seek consult
 Past Medical History
● No history of similar According to the mother,
symptoms in the past ● Non-smoker
● (-) HPN ● Non-alcoholic beverage
● (-) DM drinker
● (-) TB ● No history of illicit drug use
● (-) malignancy
● (-) allergies
● (+) asthma, last attack during
childhood
 Family Medical History
According to the mother,
● No history of similar symptoms in the family
● (+) HPN, maternal
● (+) DM, maternal
● (-) TB
● (-) malignancy
● (-) allergies
● (-) asthma
Family of Origin
Name of Patient’s Role of Patient‘s
Family General Data Relationship Description of the Illness in Family
Member Family Member Relation

61-year-old, male, His father used to The father is the

right-handed, Dating drink alcohol, primary provider and
Daan, fourth of 10 smoke, and gamble. provides the money
Veronico
children, high school Father But the patient is needed for the
Sefurida
graduate, works as a happy that his father treatment.
tricycle driver, lives in no longer does
Molino, Cavite those things.

56-year-old, female, The mother is a The mother serves

right-handed, Dating good person who as the primary
Daan, 2nd of 8 children, always takes care of caretaker of the
Shirley high school graduate, the patient and gives patient.
unemployed, lives in Mother him advices.
Sefurida
Molino, Cavite
Family of Origin
Name of Patient’s Role of Patient‘s
Family General Data Relationship Description of the Illness in Family
Member Family Member Relation

30-year-old, male, The brother can

right-handed, Dating provide moral and
The patient is close
Daan, eldest of three some financial
Jerome to his brother to
children, college graduate Older brother support to the
Sefurida whom he can ask
of BS IT, employed, lives family..
help when he can.
in Muntinlupa

26-year-old, female, The patient used to Provides emotional

right-handed, Dating be emotionally support to the family.
Daan, second of three distant from her
Mary Grace children, high school sister but they are
graduate, unemployed, Older sister now reacquianted.
Sefurida
lives in Molino, Cavite
Personal and Social History (Anamnesis)
Prenatal and Perinatal History
● The patient was planned and wanted
● Born term via VSD at home by a nurse
● No intrapartum or postpartum complications
● No medications taken
Personal and Social History (Anamnesis)
Infancy
● The patient was breastfed only for one month
● The patient had no sleeping and feeding issues
● The patient could utter syllables before one year old
● The patient could stand and walk supported by one year
old
Personal and Social History (Anamnesis)
Early Childhood
● The patient was toilet trained by the mother and achieved
bladder and bowel control by three years old
● No language and motor delay
● The patient had separation anxiety with the mother
● The patient had one gap year because he did not want to
go to school due to separation anxiety
Personal and Social History (Anamnesis)
Middle Childhood
● The patient excelled academically in elementary
● He was bullied at school by some of his classmates and
was occasionally isolated from the group
● The mother reported the bullying to the teachers
● The patient was shy but had a few friends
● The patient usually plays with his siblings and neighbors
Personal and Social History (Anamnesis)
Adolescence
● The patient excelled academically and was active in sports
● No longer reported bullying
● Did not report romantic relationships
● Did not partake in risky behaviors (alcohol, smoking, illicit
drug use)
● Seldom became involved in conflicts
Personal and Social History (Anamnesis)
Adulthood
● The patient was unable to graduate college due to financial
constraints
● Worked for several months but quit due to workplace
“bullying”
● Did not have romantic relationships
● Does not have any vice
Personal and Social History (Anamnesis)
Religion
● The patient has always been active in attending church
Personal and Social History (Anamnesis)
Current Living Condition
● The patient currently lives with both parents and one
sibling
● No domestic conflict
 Mental Status Examination
● Young adult male ● Normal volume, occasional
● Fairly groomed shouting, pressured
● Wearing black shirt and speech, sometimes
jeans incomprehensible
● In handcuffs ● Labile mood with
● Restless appropriate affect
● Cooperative, responsive, ● Auditory and visual
maintains eye contact hallucinations
● Good remote memory ● Flight of ideas
 Mental Status Examination
● Auditory and visual
hallucinations
● Flight of ideas
● Delusion of grandeur
● Oriented to person but not
to place and time
● Good remote memory, poor
immediate and recent
recall
● Unable to concentrate
● Poor fund of knowledge
● Unable to follow a
three-step command
● Poor reading, writing, and
visuospatial ability
● Concrete thinking, poor
impulse control
● Level 1 insight
Physical Examination

Vital Signs
BP: 120/80 mmHg, right arm, sitting
PR: 75 bpm
RR: 20 cpm
Temp: 36.5 °C
Physical Examination
Skin
(+) abrasions, 10x8 cm, left arm; (-)
pallor, (-) hyperpigmentation, (-)
erythema; afebrile, good skin turgor;
good capillary refill
Head and Neck
symmetrical hair distribution with
normal hair pattern, color, and
texture; (-) cervical lymphadenopathy;
midline trachea, thyroid not palpable
Eyes
pink, palpebral conjunctiva; anicteric
sclera; equal and briskly reactive
pupils; (-) discharge
Ears
(-) masses, swelling, ulceration at the
pinna and periauricular area; gross
normal hearing
Nose:
symmetrical external nose; (-)
discharge
Physical Examination
Mouth and Throat
pink, moist oral mucosa; midline tongue; non-hyperemic tonsils grade 1
Thorax
Chest rises symmetrically, no use of accessory muscles; clear breath sounds,
no adventitious sounds
Cardiovascular
Normal rate, regular rhythm; (-) S3 and S4, (-) murmurs
Abdomen
Soft, globular, non-tender; normoactive bowel sounds
Extremities
(-) digital clubbing; (-) limitation in range of motion
Physical Examination
Neurologic exam CN V: intact facial sensation
CN I: able to smell CN VII: (-) facial asymmetry
CN II: equal and bilaterally reactive CN VIII: good gross hearing
pupils CN IX, X: able to swallow
CN III, IV, VI: full range of EOM CN XI: good trapezius tone
motion
Assessment

Schizophreniform Disorder
 Plan

For Admission
Give:
Haloperidol 5 mg IM
Chlorpromazine 100 mg ½ tab HS
Risperidone 2 mg OD AM
Biperiden HCl 2 mg PRN for EPS
Diphenhydramine for sleeplessness
 PSYCHOTIC
● Insight is absent
● Judgement and Reasoning is
impaired
● Reality contact is lost
● Delusions and Hallucinations
usually presnt
● Change in personality may
be present
NEUROTIC
● Insight is present
● Judgement and Reasoning
is intact
● Reality contact is present
● Delusions and
Hallucinations usually
absent
● Change in personality
usually absent
Psychotic Disorders

● Schizophrenia
● Schizophreniform
● Schizoaffective disorder
● Brief psychotic disorder
● Delusional disorder
● Substance- or Medication-Induced Psychotic Disorder
DSM-5: Schizophrenia (F20)
DSM-5: Schizophreniform (F20.81)
DSM-5: Schizoaffective disorder (F25)
DSM-5: Brief Psychotic Disorder (F23)
DSM-5: Delusional Disorder (F22)
DSM-5: Substance- or Medication-Induced
Psychotic Disorder
 Phases of Schizophrenia
1. Acute phase……………………………………………………….
2. Stabilization phase………………………………………………..
3. Maintenance phase……………………………………………….
Acute phase of Schizophrenia
● Acute psychotic episode
● New onset or acute exacerbation of symptoms
● Typically associated with severe agitation, delusions,
hallucinations or suspiciousness or from other causes (e.g.
stimulant abuse)
● Lasts for 0-3 months
Stabilization phase of Schizophrenia
● Follows the acute phase
● Lasts from 3 - 6 months
Maintenance phase of Schizophrenia
● Persistent and chronic schizophrenia
● Usually in a relative state of remission with only minimal
psychotic symptoms
Management of the Acute Phase
Treatment goals
● Alleviate the most severe psychotic symptoms
● Prevent harm to self and others
● Determine and address the factors that led to the acute
episode
● Formulate short and long term treatment plans
● Usually lasts from 4-8 weeks
Management of the Acute Phase
Managing agitation
1. Verbal de-escalation
2. Restraints (physical or chemical)
3. Isolate and fully monitor the patient
4. Physical and medical examination once stable
Management of the Acute Phase
Managing agitation
● Antipsychotics
○ IM injection of Haloperidol —> calming effect without excessive
sedation
● Benzodiazepines
○ Lorazepam OD or IM
○ May reduce the amount of antipsychotics needed to control the
patient
Management of the Stabilization and
Maintenance phase
Treatment goals

● Prevent psychotic relapse

● Assist patients in improving their level of functioning
Management of the Stabilization and
Maintenance phase
Treatment

● Psychopharmacological treatment is the cornerstone of

management
 TYPICAL
ANTIPSYCHOTICS

ATYPICAL
ANTIPSYCHOTICS
 Typical antipsychotics

● Dopamine receptor antagonists

● High-potency
○ D2 dopamine receptor antagonists
○ Higher risk for EPS
○ e.g. Fluphenazine, Haloperidol, Pimozide
● Low-potency
○ Less affinity to D2 receptors, interact with non-dopaminergic
receptors —> more cardiotoxic and anticholinergic effects
○ e.g. Chlorpromazine, Thioridazine
 Atypical Antipsychotics

● Block D2 receptors —> reducing positive symptoms and

stabilising affective symptoms
● Block serotonin 2A receptors —> reducing motor side effects
and improving cognitive and affective symptoms
● Olanzapine, Quetiapine, Clozapine, Aripiprazole,
Risperidone