Psychosis

Andi J Tanra
Faculty of Medicine, Hasanuddin
University, Makassar, 2020
Psychosis is characterized by a loss of contact with
reality
• Delusions (fixed false beliefs)
• Hallucinations (false sensory perceptions)
• Disorganized speech
• Disorganized behavior
Caused by a variety of conditions that affect the
functioning of the brain.
These problems lead to social or occupational
dysfunction
 P
Mood disorders S
Y Substance
C induced
“organic” mental
H disorders
“Functional” O
disorders S Delirium
Schizophrenia
“spectrum” disorders I Dementia
S Amnestic d/o
 Psychosis Epidemiology
3.7% of primary care patients report at least one
psychotic symptom
Most common symptom is believing that others are
spying on or following the individual
Up to 30% of individuals with psychotic symptoms rely
solely on primary care
5% lifetime risk of suicide
 Psychosis – Psychological Causes
• Schizophrenia
• Schizoaffective Disorder
• Brief Psychotic Disorder
• Major Depressive Disorder
• Bipolar I Disorder
• Unspecified Psychotic Disorder
• Delusional Disorder
• Personality Disorders
• Narcolepsy
 Psychosis subtances induced caused

• Alcohol
• Cannabis
• Cocaine
• Amphetamine
• Methamphetamine
• Mephedrone (MCAT)
• MDMA (ecstasy)
• LSD (acid)
• Ketamine
 Psychosis medical cause
• Epilepsy • Endocrine Disorders
• Head injury • Thyroid disorders
• Hypoglycemia
• Brain tumors
• Cushing’s Disease
• Infections
• Dementias
• Malaria
• Alzheimer’s Disease
• Syphilis
• Parkinson's disease
• Lyme Disease
• Lewy Body Dementia
• HIV and AIDS
• Metabolic Disorders
• Autoimmune Disorders • Acute Intermittent
• Lupus Porphyria
• Multiple sclerosis
 Screening Psychosis
Normalize the experience
•Sometimes when people are [under stress
or feeling anxious/depressed], they can have
strange experiences such as trouble with
thinking or seeing or hearing things that
others don’t.
• The next questions are about unusual
things, like seeing visions or hearing voices
that some people may not believe in. In fact
these things may be quite common in certain
situations.
 Screening for Psychosis
• Have your eyes or ears (or brain) ever played tricks
on you?
• Have there ever been times when you heard or saw
things that other people could not?
• Have you ever heard voices that other people could
not hear? I don't mean having good hearing, but
rather…voices coming from inside your head talking
to you or about you, or voices coming out of the air
when there was no one around. Did you ever hear
voices in this way?
 Screening for Psychosis
• Have you had any strange or odd experiences
lately that are difficult to explain or that others
would find hard to believe?
• Have you felt people are watching or following
you?
• Does anyone in particular seem intent on
harassing or hurting you?
• Have you felt like others can hear your thoughts
or that you can hear another person’s thoughts?
 Screening Psychosis
• Has a doctor ever told you that you have
schizophrenia?
• Who in your family has had problems with
psychosis or schizophrenia?
• Do you have any special powers that most
people lack?
 Psychosis initial managment
• Evaluate for safety
• Refer for psychiatric evaluation
• EASA referral for first psychosis
• If no safety concerns exist and there is no timely
referral available, consider starting an
antipsychotic
• Go with what’s worked best in the past
• Risperidone or Perphenazine if no prior
 Managment
• Psychopharmacological Treatment
• Hospitalization
• Electroconvulsive therapy
• Psychotheraphy
• Cognitive Therapy
 Schizophrenia Disorder :
What Do We Know? Where Do We Go

Andi Jayalangkara Tanra

Departemen Psikiatri
Fakultas Kedokteran
Universitas Hasanuddin
Makassar.
 SKIZOFRENIA
GGN BERAT DLM BIDANG : PIKIRAN, PERASAAN, PERBUATAN,
PERSEPSI, KEINGINAN, DORONGAN KEHENDAK &
PENGENDALIAN

ONSET SULIT DITENTUKAN,BIASANYA DI DAHULUI FASE

PRODROMAL (GEJALA RINGAN & TDK KONSISTEN)

GEJALA PSIKOLOGIK MAJEMUK : DISTORSI PIKIRAN & PERSEPSI

→ WAHAM & HALUSINASI YG KHAS, AFEK TDK WAJAR /
TUMPUL, SIKAP/PERILAKU ANEH, PERASAAN & PIKIRAN
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LUAR

PERJALANAN PENY SULIT DITENTUKAN, KRONIS, DETERIORASI

TERGANTUNG : GENETIK, FISIK & SOSIAL BUDAYA.
 Wh  at is Schizophrenia  ?

• Dementia praecox • Group of • First-rank symptoms

Krepelin (1887)

Bleuler (1911)
• Based on his schizophrenias • Auditory

Schneider (1938)
longitudinal • Basic hallucinations,
observations of (obligatory) • Broadcasting of
clinical cases which symptom thought,
ultimately resulted in • loosening of • Controlled thought
severe cognitive and associations, (delusions of
behavioral decline ambivalence, control),
affective • Delusional
incongruence, and perception
autism
• Accessory
(supplementary)
• Delusions &
hallucinations

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181977/
 Diagnosis of Schizophrenia: DSM-5
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). At least one of these must be
1, 2, or 3.
1) Delusions
2) Hallucinations
3) Disorganized speech (freq. derailment or incoherence)
4) Grossly disorganized or catatonic behavior
5) Negative symptoms (i.e., diminished emotional
expression or avolition

Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

American Psychiatric Publishing, Washington DC, 2013
 Diagnosis of Schizophrenia: DSM-5
B. Social/occupational dysfunction
C. Duration: Continuous signs for at least 6 months
(psychosis + prodrome + residual sx)
D. Schizoaffective and psychotic mood disorder have been
excluded
E. Not attributable to substance or general medical
condition
F. Not a manifestation of a pervasive developmental
disorder

Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

American Psychiatric Publishing, Washington DC, 2013
 Features of Schizophrenia
Positive Symptoms Negative Symptoms
Loss of insight • Affective flattening
• Delusions
(anosognosia) • Anhedonia
• Hallucinations
• Disorganization • Alogia
• Catatonia • Avolition
• Social withdrawal
Social/Occupational Dysfunction
• Work
• Interpersonal relationships
• Self-care

Cognitive Deficits Mood Symptoms

• Attention • Depression
• Memory Comorbid • Hopelessness
• Executive functions Substance Abuse • Suicidality
(eg, abstraction) • Anxiety
• Agitation
Adapted from Maguire GA, 2002 • Hostility
 Other structural abnormalities

• Decreased volume:
– Medial temporal (limbic) structures (hippocampus, et
– Prefrontal cortex
– Thalamus, esp. mediodorsal nucleus
• White matter abnormalities
• Striatal changes
• Deviations from normal asymmetry
Failure of normal cellular organization in
prefrontal cortex

Normal

Patients with schizophrenia

Selemon et al. Arch Gen Psychiatry 1995; 52:805
 Natural History of Schizophrenia
Stages Of Illness

Premorbid Prodromal Onset/ Residual/

Deterioration Stable
Healthy


Worsening
Severity Of
Signs And
Symptoms

10 prevention Remediation Rehabilitation

20 Prevention

10 20 30 40 50
Gestation/Birth
Years From Lieberman et al
Course
Delusions Negative symptoms
Hallucinations Cognitive symptoms
Strong affects Thought Disorder
 Dopamine systems
Clinical
Cell bodies Projections Functions implications
Nigro- Substantia Caudate
and
Move-
ment
Extrapyramidal
symptoms, dystonias,
Nigra
striatal putamen Tardive dyskinesia

Meso- Ventral
tegmental
Accumbens
amygdala
Emotions,
affect,
Positive symptoms

limbic area, subst. Olfactory memory

nigra tubercle

Meso- Ventral
tegmental
Prefrontal Thought,
volition,
Blockade here can
worsen negative
Cortex
cortical area memory symptoms.
 Etiology of Schizophrenia:
Evaluation of Dopamine Theory
• Dopamine theory doesn’t completely explain
disorder
– Antipsychotics block dopamine rapidly but symptom
relief takes several weeks
– To be effective, antipsychotics must reduce dopamine
activity to below normal levels
• Other neurotransmitters involved:
– Serotonin
– GABA
– Glutamate
• Medication that targets glutamate shows promise
© 2012 John Wiley & Sons, Inc. All rights
reserved.
Glutamate, GABA and the NMDA receptor

• Psychotomimetic effect of PCP (NMDA

antagonist)
• Abnormalities in glutamate levels,
release, receptors in schizophrenia
Dopamine Theory of Schizophrenia

© 2012 John Wiley & Sons, Inc. All rights

reserved.
 Positive Symptoms:
Behavioral Excesses and Distortions
• Delusions • Hallucinations
– Firmly held beliefs – Sensory experiences in the
– Contrary to reality absence of sensory
– Resistant to disconfirming stimulation
evidence
• Types of delusions:
– Persecutory delusions
• “The CIA planted a listening device • Types of hallucinations:
in my head”
• 65% have these
– Auditory
• 74% have this symptom
– Thought insertion
– Visual
– Thought broadcasting
– Hearing voices
– Outside control • Increased levels of activity in
– Grandiose delusions Broca’s area during hallucinations
– Ideas of reference
© 2012 John Wiley & Sons, Inc. All rights
reserved.
 Negative Symptoms:
Behavioral Deficits
• Avolition • Can be grouped into 2
– Lack of interest; apathy
domains:
• Asociality
– Inability to form close personal
– Experience domain
relationships • Motivation
• Anhendonia • Emotional experience
– Inability to experience pleasure • sociality
• Consummatory pleasure
• Anticipatory pleasure
– Expression domain
• Blunted affect • Outward expression of
– Exhibits little or no affect in face emotion
or voice • Vocalization
• Alogia
– Reduction in speech

© 2012 John Wiley & Sons, Inc. All rights

reserved.
 Psychological Theories
• Freud – delusions as a way of making sense of
the external world
• Klein – failure to resolve the paranoid/schizoid
position
• Cameron – loss of conceptual boundaries
• Goldstein – concrete thinking
• Difficulties in filtering senory input?
 Psychosocial Factors
• Expressed emotion
• Stressful life events
• Low socioeconomic class
• Limited social network
 Typical Neuroleptics
• High
Low potency:
potency:
– Haloperidol
Chlorpromazine
– Fluphenazine
Thioridazine
– Thiothixene
Mesoridazine
– Loxapine (mid)
 Neuroleptic (typicals):
side effects
• Acute dystonia
• Parkinsonian side effects (EPS)
• Akathisia
• Tardive dyskinesia
• Sedation, orthostasis, QTC prolongation,
anticholinergic, lower seizure threshold,
increased prolactin
 Atypical Antipsychotics:
• Risperidone
• Olanzapine
• Quetiapine
• Clozapine
• Ziprasidone
• Aripiprazole (new-partial DA agonist)
Atypical Antipsychotics: Side Effects
• Sedation
• Hyperglycemia, new-onset diabetes
• Anticholinergic effects
• Less prolactin elevation
• QTC prolongation
• Some EPS
• Increased lipids
 Psychological Treatments
• Family therapy to reduce Expressed Emotion
– Educate family about causes, symptoms, and signs of
relapse
– Stress importance of medication
– Help family to avoid blaming patient
– Improve family communication and problem-solving
– Encourage expanded support networks
– Instill hope

© 2012 John Wiley & Sons, Inc. All rights

reserved.
 Psychological Treatments
• Cognitive behavioral therapy
– Recognize and challenge delusional beliefs
– Recognize and challenge expectations associated with negative
symptoms
• e.g., “Nothing will make me feel better so why bother?”
• Cognitive remediation training or cognitive enhancement
therapy (CET)
– Improve attention, memory, problem solving and other cognitive-
based symptoms
• Case management
– Multidisciplinary team to provide comprehensive services
• Residential treatment
– Vocational rehabilitation
© 2012 John Wiley & Sons, Inc. All rights
reserved.
 Psychosocial Treatment
• Education, compliance #1
• Hospitalize for acute loss of functioning
• Outpatient treatment is rehabilitative
• Psychoanalysis, exploratory therapies have
limited value
• Families should be involved
 Psychotic Disorders
Onset Symptoms Course Duration

Schizo- Usually Many Chronic >6 months

insidious
phrenia
Delusional Varies Delusions Chronic >1 mo.
(usually only
disorder insidious)
Brief Sudden Varies Limited <1 mo.

psychotic
disorder
 Delusional Disorder and
Shared Psychotic Disorder
 F22.0 Delusional Disorder
• A disorder characterized by the development of one
delusion or of the group of similar related delusions,
which are persisting unusually long, very often for
the whole life.
• Other psychopathological symptoms —
hallucinations, intrusion of thoughts etc. are not
present and are excluding this diagnosis.
• It begins usually in the middle age.
 F24 Induced Delusional Disorder
• A delusional disorder shared by two or more people
with close emotional links. Only one of the people
suffers from a genuine psychotic disorder; the
delusions are induced in the other(s) and usually
disappear when the people are separated.

• The psychotic disorder of the dominant member of

this dyad is mainly, but not necessarily, of
schizophrenic type. The original delusions of
dominant member and his partner are usually
chronic, either persecutory or megalomanic.
• Delusions are false fixed beliefs not in keeping with
the culture
• Difficult to treat
• The diagnosis of delusional disorder is made when a
person exhibits nonbizarre delusions of at least 3
month's duration
• Nonbizarre means that the delusions must be about
situations that can occur in real life, such as being
followed, infected, loved at a distance, and so on;
that is, they usually have to do with phenomena that,
although not real, are nonetheless possible
 Epidemiology
• Relatively rare
• Underreported  delusional patients rarely
seek psychiatric help unless forced to do so by
their families or by the courts
• Estimated to be 0.025 to 0.03 percent (USA)
• The mean age of onset: 40 years (18 - 90
years)
• Men > women  erotomania
 Etiology
• Unknown
• Biological Factors: the limbic system and the basal ganglia
(intact cerebral cortical functioning)
• Psychodynamic Factors: hypersensitive persons and specific
ego mechanisms: reaction formation, projection, and denial
• Psychodynamic Factors: a general distrust of their
environment
• 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
 Diagnostic Criteria for Delusional Disorders
• A delusion or a set of related delusions, other than
those listed as typically schizophrenic in Criterion for
paranoid, hebephrenic, or catatonic schizophrenia
(i.e., other than completely impossible or culturally
inappropriate), must be present. The commonest
examples are persecutory, grandiose,
hypochondriacal, jealous (zelotypic), or erotic
delusions.
• The delusion(s) must be present for at least 3
months.
• The general criteria for schizophrenia are not
fulfilled.
• There must be no persistent hallucinations in any
modality (but there may be transitory or occasional
auditory hallucinations that are not in the third
person or giving a running commentary).
• Depressive symptoms (or even a depressive episode)
may be present intermittently, provided that the
delusions persist at times when there is no
disturbance of mood.
• Most commonly used exclusion clause. There must
be no evidence of primary or secondary organic
mental disorder as listed under organic, including
symptomatic, mental disorders, or of a psychotic
disorder due to psychoactive substance use
• Delusional disorders that have lasted for less than 3
months should, however, be coded, at least
temporarily, under acute and transient psychotic
disorders
 Shared Psychotic Disorder
• Shared psychotic disorder was first described by two French
psychiatrists, Lasegue and Falret in 1877
• Also referred to over the years as shared paranoid disorder,
induced psychotic disorder, folie á deux, folie impose, and
double insanity
• It is probably rare, but incidence and prevalence figures are
lacking, and the literature consists almost entirely of case
reports
• Characterized by the transfer of delusions from one person to
another
• Both persons are closely associated for a long time and
typically live together in relative social isolation
• In its most common form, the individual who first has the
delusion (the primary case) is often chronically ill and typically
is the influential member of a close relationship with a more
suggestible person (the secondary case) who also develops
the delusion
 Diagnostic Criteria for Induced
Delusional Disorder
• The individual(s) must develop a delusion or delusional
system originally held by someone else with a disorder
classified in schizophrenia, schizotypal disorder, persistent
delusional disorder, or acute and transient psychotic
disorders.
• The people concerned must have an unusually close
relationship with one another, and be relatively isolated from
other people.
• The individual(s) must not have held the belief in question
before contact with the other person, and must not have
suffered from any other disorder classified in schizophrenia,
schizotypal disorder, persistent delusional disorder, or acute
and transient psychotic disorders in the past
 Differential Diagnosis
• Medical Conditions: Neurodegenerative
disorders, Other central nervous system
disorders, Vascular disease, Infectious disease,
Metabolic disorder, Endocrinopathies, Vitamin
deficiencies, Substances, Toxins
• Delirium, Dementia, and Substance-Related
Disorders
 F25 Schizoaffective Disorders
• Episodic disorders in which both affective and schizophrenic
symptoms are prominent (during the same episode of the
illness or at least during few days) but which do not justify a
diagnosis of either schizophrenia or depressive or manic
episodes.
• Patients suffering from periodic schizoaffective disorders,
especially with manic symptoms, have usually good prognosis
with full remissions without any remaining defects.
• They are divided in different subgroups:
– F25.0 Schizoaffective disorder, manic type
– F25.1 Schizoaffective disorder, depressive type
– F25.2 Schizoaffective disorder, mixed type
– F25.8 Other schizoaffective disorders
– F25.9 Schizoaffective disorder, unspecified
Introduction – Diagnosis – Studies – Perspective

Bipolar Spectrum

Mania

Hypomania

Normal

Depression

severe
Depression
Normal Zyklothymic Zyklothymia Bipolar II Unipolar Bipolar I
mood- personality Disorder Mania Disorder cycle

__________________________________________________________________________________________________________
Goodwin et al. Manic-depressive Illness. Oxford: Oxford University Press, 1990
Causes
Scientists don’t know the exact cause of schizoaffective disorder.
Things that may be involved include:
Genetics (heredity): Someone may inherit a tendency to develop
schizoaffective disorder from their parents.
Brain structure and function: People with schizophrenia and
mood disorders may have problems with brain circuits that
manage mood and thinking.
Environment: Environmental things -- such as a viral infection,
bad relationships, or highly stressful situations -- may trigger
schizoaffective disorder in people who are at risk for it. How that
happens isn’t clear.
Diagnosis
There are no laboratory tests to specifically diagnose schizoaffective
disorder. So doctors rely on a person's medical history -- and may
use various tests such as brain imaging (like MRI scans) and blood
tests -- to make sure that a physical illness isn’t the reason for the
symptoms.
In order to diagnose someone with schizoaffective disorder, the
person must have periods of uninterrupted illness and, at some
point, an episode of mania, major depression, or a mix of both,
while also having symptoms of schizophrenia. The person must also
have had a period of at least two weeks of psychotic symptoms
without the mood (depression or bipolar) symptoms.
Treatment for schizoaffective disorder includes:
Medication : Some of the medicine a person needs depends on whether they have
depression or bipolar disorder, along with schizophrenia. The main medications that
doctors prescribe for psychotic symptoms such as delusions, hallucinations, and
disordered thinking are called antipsychotics. All antipsychotic drugs likely have value
in the treatment of schizoaffective disorder, but paliperidone extended release
(Invega) is the only drug that the FDA has approved to treat schizoaffective disorder.
For mood-related symptoms, someone may take an antidepressant medication or a
mood stabilizer such as lithium. They often will also take an antipsychotic medication.
Psychotherapy : The goal of this type of counseling is to help the person learn
about their illness, set goals, and manage everyday problems related to the
disorder. Family therapy can help families become more effective in relating to and
helping a loved one who has schizoaffective disorder.
Skills training: This generally focuses on work and social skills, grooming and self-
care, and other day-to-day activities, including money and home management.
Hospitalization: Psychotic episodes may require a person to be hospitalized,
especially if he/she is suicidal or threatens to hurt others.

Can You Prevent Schizoaffective Disorder?

No. But if someone gets diagnosed and starts treatment ASAP, it can help a person
avoid or reduce frequent relapses and hospitalizations and help decrease the
disruption to the person's life, family, and friendships.
TERIMA KASIH