Prepared by: Mesgana Dereje

Rebecca shisema
Moderator: Dr. Teketel
Outline

■ Objective
■ Introduction
■ Historical perspective
■ Epidemiology
■ Risk factors
■ Etiology
■ Pathophysiology
■ Types of schizophrenia
Cont.…

■ Signs and symptoms

■ DSM-5 Diagnostic Criteria for Schizophrenia
■ Development and course
■ Differential diagnosis
■ Treatment
■ Summary
■ Reference
Objective

■ Explain the meaning of Psychosis

■ Explain the etiology and types of psychosis
■ Explain the diagnosis and treatment
Case

■ A 25-yo woman has been hospitalized in a psychiatry ward since April 2020 . She
thinks she is in the lockdown and spends most of her day rocking, muttering softly to
herself, or looking at her reflection in a small mirror. She believes the digital Junta
encircled her and does not want any one to be around her . she often giggles and laughs
for no apparent reason. she developed the belief that her vision was failing because of
poisons secretly placed in her food by former neighbors. She frequently yells`` I do not
concede the victory of Biden… I like Trumpet !``. A You-Tuber released nude video
of her that she believed was placed there to shame her publicly. She said that cars
passing up and down the street contained agents who were spying on her. she believed
that the electric light bulbs in her room were emanating a purifying radiation to
counteract corona virus , which she was supposedly breathing into the atmosphere,
although a lab test was negative for Covid-19.
 Psychosis
A significant break with normal reality or functioning.

(1) hallucinations,
(2) paranoia or delusions,
(3) disorganized thinking or speech,
(4) disorganized or catatonic behavior
Types
 Schizophrenia

■ Schizophrenia literally means “Fragmented Mind”

■ The term was coined by Eugen Bleuler to express the fragmentation of

thought, emotion, behavior

■ It represents a heterogeneous syndrome of disorganized thoughts,

delusions, hallucinations, and impaired psychosocial functioning
 History
■ Written descriptions of symptoms commonly observed today in patients
with schizophrenia are found throughout history.
■ Early Greek physicians described delusions of grandeur, paranoia, and
deterioration in cognitive functions and personality.
■ It was not until the 19th century, however, that schizophrenia emerged as
a medical condition worthy of study and treatment.
Emil Kraepel in, 1856-1926. Eugene Bleuler, 1857-1 939.

Dementia praecox Schizophrenia

Emil Kraepel

■ A German psychiatrist, classify mental illness to Dementia praecox and manic

depressive disorders.

■ Characteristics includes delusions, hallucinations, disturbances of affect and motor

disturbances
Eugene Bleuler

■ Swiss psychiatrist renamed dementia praecox as schizophrenia in 1908. from Greek

words schizo-split and phren–mind
■ He described symptoms as fundamental and accessory symptoms. The fundamental
symptoms are known as the 4 A’s of Eugene.
■ Asociality, avoliation, anhedonia and Alogia
Epidemiology

■ Affects 20 million people worldwide

■ Lifetime prevalence of approximately 0.50% in the United States and globally
■ Men and women are equally affected, but with a slight difference in the age of onset
– Men: average age of onset = 23 years
– Women: average age of onset = 26 years
Risk factors

■ Gender and Age

■ Medical illness
■ Infection
■ Substance abuse
■ Socioeconomic and cultural factors.
Etiology
Biologic Non- biologic
– Psychoanalytic Theories
– Biochemical changes
– Learning theories
– Structural changes
– Family Dynamics
– Genetic
– Psychosocial
– Physiological changes
– Psychoneuroendocrinology
Biochemical changes

• Three neurotransmitters play a role

-Dopamine
-Serotonin
-Glutamate
1. Dopaminergic theory:

■ Almost all drugs with antipsychotic properties block the dopaminergic D2 receptor.
■ However, antipsychotics are only 70% effective and clozapine, the most effective
antipsychotic for treating schizophrenia, is a weak D2 antagonist.
■ Hyperactivity of dopamine D2 receptor neurotransmission in subcortical, and limbic
brain regions contribute to the positive symptoms of schizophrenia.
■ Hypofunctionality of dopamine D1 receptor neurotransmission in the prefrontal cortex
contributes to both negative and cognitive symptoms.
Other theories:

■ Hypofunction of the N-methyl-D-aspartate (NMDA) glutamate receptor

■ Dysfunctional gamma-amino-butyric acid (GABA) interneurons
■ Dysfunctional nicotinic acetylcholine receptors
2. Serotonin hypothesis

■ Serotoninergic receptors are present on dopaminergic axons and it is known that

stimulation of these receptors will decrease DA release in prefrontal cortex.

■ Patients with schizophrenia with abnormal brain scans have higher whole blood 5-HT
concentrations
3. Glutamate Hypothesis

■ NMDA receptor hypo function is thought to reduce the level of activity in mesocortical
dopaminergic neurons

■ On the other hand, NMDA receptor hypofunction is thought to enhance activity in the
mesolimbic dopaminergic pathway
Structural changes

■ Lateral and third ventricular enlargement

■ Reduced symmetry in temporal, frontal, and occipital lobes
■ Decrease in the size of the limbic system, including the amygdala, the hippocampus,
and the parahippocampal gyrus
■ Pathological or chemical abnormalities in the cerebral cortex, the thalamus, and the
brainstem
■ Some reduction in cortical volume
Genetic causes

■ According to WebMD If your parent, brother, or sister has schizophrenia chances of

getting schizophrenia go up by 10%. If both your parents have it, you have a 40%
chance of getting it
■ But unlike other diseases there no “schizophrenic” gene but it is a combination of genes
that cause the disease
■ Psychoneuroendocrinology
– Hormonal abnormality- hypothalamic-pitutary axis
 TYPES OF
SCHIZOPHRENIA

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1. Paranoid schizophrenia

■ Common form of schizophrenia

■ Prominent hallucinations and/or delusions of persecution or grandeur

■ Tense, suspicious, guarded, reserved, and sometimes hostile or aggressive

■ May develop at a later age than other types of schizophrenia

■ Speech and emotions may be unaffected

■ At risk for suicidal or violent behavior under influence of delusions

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2.Hebephrenic / Disorganized schizophrenia

■ Behavior is disorganized and without purpose

■ their social behavior and their emotional responses are inappropriate

■ Thoughts are disorganized, difficult to understand by others

■ Pranks, giggling, health complaints, grimacing and mannerisms are common

■ Usually develops between 15-25

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3. Catatonic schizophrenia

■ Rarer than other types

■ Classic feature of the catatonic type is a marked disturbance in motor function

■ At risk for malnutrition, exhaustion or self-injury

■ Unusual movements, often switching between extremes of over- activity and stillness

■ Unable to talk (Catatonia)

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4.Undifferentiated schizophrenia
■ Some characteristics of paranoid, hebephrenic or catatonic schizophrenia,
but does not obviously fit one of these types

5. Residual schizophrenia
■ Past History of psychosis but only having negative symptoms

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Sign and symptoms
1. Hallucinations

• Are perception-like experiences that occur without an external stimulus.

• May occur in any sensory modality.
• Auditory
• Visual
• Tactile
• Olfactory
• gustatory

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2.Delusions

• Fixed, false beliefs

• Not shared by the person’s culture.
• Cannot be changed by reasoning.
• Non-bizarre
• Plausible in ordinary life
• Bizarre
• Clearly implausible
• Not understandable to same-culture peers
• Do not derive from ordinary life experiences

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3. Disorganized Thinking (formal
thought disorder)
– Is typically inferred from the individual's speech.
– May switch from one topic to another (derailment or loose associations).
– Answers to questions may be obliquely related or completely unrelated
(tangentiality).
– Severely disorganized that it is nearly incomprehensible (incoherence or "word
salad").
– Mildly disorganized speech is common and nonspecific

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4. Grossly Disorganized or Abnormal Motor
Behavior (including Catatonia)
• Childlike "silliness" to unpredictable agitation
• Problems may be noted in any form of goal-directed behavior
• leading to difficulties in performing activities of daily living
• Psychomotor agitation-retardation
• Catatonic behavior is a marked decrease in reactivity to the environment -
• Negativism, posture, stupor ,catatonic excitement, stereotyped movements, staring,
grimacing, mutism, and the echoing of speech

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Catatonia- as specifier, mainly
Three (or more) of the following symptoms:
1. Stupor - i.e., no psychomotor activity
2. Catalepsy - i.e., passive induction of a
posture
3. Waxy flexibility - i.e., slight, even resistance
4. Mutism - i.e., no, or very little, verbal
response
5. Negativism - i.e., opposition or no response
6. Posturing - i.e., maintenance of a posture against
gravity.
7. Mannerism - i.e., odd, circumstantial caricature of
normal actions.
8. Stereotypy - i.e., repetitive, non-goal-directed
movements
9. Agitation - not influenced by external stimuli.
10. Grimacing
11. Echolalia - i.e., mimicking another’s speech
12. Echopraxia - i.e., mimicking another’s movements
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5. Negative Symptoms

• Noticeable deficits in normal behavior

• Two negative symptoms are particularly prominent in schizophrenia:

• Diminished emotional expression -reductions in the expression of emotions-in the face, eye

contact, intonation of speech (prosody), and movements of the hand, head, and face that
normally give an emotional emphasis to speech.
• Avolition is a decrease in motivated self-initiated purposeful activities- may sit for long

periods of time and show little interest in participating in work or social activities.

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• Alogia is manifested by diminished speech output.

• Anhedonia is the decreased ability to experience pleasure from positive stimuli

or a degradation in the recollection of pleasure previously experienced.

• Asociality - apparent lack of interest in social interactions and may be

associated with avolition.

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1. SCHIZOPHRENIA
Specify if

The following course specifiers are only to be used after a 1-year duration of the disorder and if they are
not in contradiction to the diagnostic course criteria.
1. First episode, currently in acute episode:
2. First episode, currently in partial remission:
3. First episode, currently in full remission: Full remission is a period of time after a previous episode
during which no disorder-specific symptoms are present.
4. Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum
of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).
5. Multiple episodes, currently in partial remission
6. Multiple episodes, currently in full remission
7. Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the
majority of the illness course, with subthreshold symptom periods being very brief relative to the overall
course.
8. Unspecified
HISTORY AND MENTAL
STATUS EXAMINATION
History(Premorbid personality)

■ In the typical history of schizophrenic patients, patients mostly had schizoid or schizotypal
personalities characterized as quiet, passive, and introverted and as children, they had few friends.
■ Pre-schizophrenic adolescents may not have good social interaction. They may enjoy doing things
alone.
■ Some adolescent patients may show a sudden onset of obsessive-compulsive behavior as part of the
prodromal picture.
 Commonly have complaints about somatic symptoms
-Headache -Back
and muscle pain
-weakness, and digestive problems
 During this stage, a patient may begin to develop an interest in abstract ideas, philosophy, and the
occult or religious questions.
Mental status examination

 General description-can range from that of a completely disheveled, screaming, agitated person to
an obsessively groomed, completely silent, and immobile person
 Appearance-are often -poorly groomed
-Fail to bathe
 Perceptual Disturbances-Any of the five senses may be affected by hallucinatory experiences in
patients with schizophrenia. The most common hallucinations are auditory, with voices that are often
threatening, obscene, accusatory, or insulting.
Two or more voices may converse among themselves, or a voice may comment on the patient's life or
behavior.
Cont..

■ Illusion mostly occur in active phases of the schizophrenia but it can occur in other stages of the
disease too.
■ Thought-Delusions are most common thought content problem
-Disorders of the form of thought are
associations, derailment, incoherence, tangentiality,
circumstantiality, neologisms, echolalia word salad and mutism.
Cont..

■ Thought content Problems include-flight of ideas, thought blocking, impaired attention, poverty of
thought content, poor abstraction abilities, perseveration, clang associations, over-inclusion, and
circumstantiality.
Cognition
■ Orientation- Patients with schizophrenia are usually oriented to person, time, and place.
■ Memory-Memory is usually intact.
■ Judgment and Insight-Classically patients with schizophrenia are described as having poor insight
into the nature and the severity of their disorder.
Associated Features Supporting Diagnosis

• Inappropriate affect (e.g., laughing in the absence of an appropriate stimulus)

• Hostility and aggression
• A disturbed sleep pattern (e.g., daytime sleeping and nighttime activity)
• Depersonalization, derealization
• Somatic concerns -reach delusional proportions
• Cognitive deficits - common - memory, language function, and other executive functions, as well
slower processing speed
• Inability to infer the intentions of other people (theory of mind)
• Neurological soft signs - Impairments in motor coordination, sensory integration, motor sequencing
of complex movements and Left-right confusion.

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Clinical features

■ The characteristic symptoms of schizophrenia involve a range of cognitive, behavioral, and

emotional dysfunctions.

■ General rule:
– No clinical sign or symptom is pathognomonic for schizophrenia.
– A patient's symptoms change with time.
– Clinicians must take into account the patient's educational level, intellectual ability, and
cultural and subcultural membership.

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Clinical features

A. Overall functioning:
- Level of functioning declines or fails to achieve the expected level

B. Thought content Abnormal

- Delusions:- is the most common one seen in this condtion.
- may assume persecutory, grandiose

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Cont.

C. Form of thought:
- Tangentiality
- Loosening of association
- Circumstantiality
- Blocking
- Echolalia
- pressured speech

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Cont.

D. Perception Distorted
- hallucinations
- Auditory hallucination:- most common hallucinations
-With voices that are often threatening, accusatory, or insulting.
- Two or more voices may converse among themselves, or a voice may comment on the patient's
life or behavior.
- Visual hallucinations are also common.

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Cont.

E. Affect
- Two common affective symptoms in schizophrenia are:
- Reduced emotional responsiveness;
- Overly active and inappropriate emotions such as extremes of rage, happiness, and anxiety.

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Cont.

G. Volition altered
Inadequate drive or motivation
H. Interpersonal Functioning impaired
• Social withdrawal
• Aggressiveness, impulsiveness, violence, suicide
• Sexual inappropriateness
I. psychomotor /behavior Abnormal or changed
Agitation withdrawal posturing, etc.
J. Cognition impaired
e.g. Lack of concentration, Inattention, impaired information processing

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Differential diagnosis

■ Substance induced Psychotic

disorder:-amphetamine,
hallucinogens, alcohol
hallucinosis, barbiturate
withdrawal, etc..

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■ Did you know that the
strongest predictor of
treatment outcome in first-
episode schizophrenia?
Duration of presenting
symptoms before treatment
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 Treatment

1. Antipsychotic medications
– The first line psychiatric treatment for many psychotic disorders is antipsychotic medication
– Can reduce the positive symptoms of psychosis
2. ECT
3. Psychosocial interventions

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Classification

Older agents:
■ typical/conventional/dopamine receptor antagonists/major tranquilizers/neuroleptics
• Improved positive signs due to decreased dopamine in the mesolimbic pathway
• Worsening of the negative symptoms due to decreased dopamine in the mesocortical
pathway.

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Newer agents

■ Atypical/serotonin-dopamine antagonists/second generation/limbic specific

■ Improvement in the negative signs due to increase of dopamine in the mesocortical pathway
■ Increases dopaminergic firing rate in the nigrostriatal pathway so it has less extrapyramidal side
effect.

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Adverse effects

1. SEDATION
• Sedation is most commonly associated with low potent typical antipsychotics like chlorpromazine and
clozapine, it is primarily related to dosage with other antipsychotics.

2. AUTONOMIC SIDE EFFECTS

• associated with changes to the QT interval measured on the ECG and, if given in high doses, may
increase the risk of sudden cardiac death due to α adrenergic blockage.
• dry mouth, constipation, blurred vision, decreased sweating, increased pupil size, urinary
• Postural hypotension, palpitation, inhibition of ejaculation

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Extrapyramidal Side Effects (EPS)

1. Acute dystonic reaction: usually within the first 4 days, it is an abrupt, distressing, painful,
sustained contraction/spasm of the muscles of the neck, eyes, mouth, tongue, trunk or extremities.
Treatment: Intramuscular Benztropine or Diphenhydramine.

2. Pseudoparkinsonism: tremor, rigidity, hypokinesia: usually has later onset than acute dystonias.
Treatment: try to reduce antipsychotic dose if possible and/or add an antiparkinsonism (e.g.,
anticholinergic) agent such as Benztropine.

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3. Akathisia: anxiety, tension, restlessness, may feel compelled to pace or tap feet.
Treatment: similar to that for Pseudoparkinsonism,

4. Tardive Dyskinesia : A movement disorder that may occur following long-term treatment with
antipsychotic medications- often irreversible.
 mouth and tongue movements, such as lip smacking, sucking and puckering as well as facial
grimacing
 irregular movements of the limbs
Treatnent: reduction of the dose of the antipsychotic, switching to another antipsychotic

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Neuroleptic Malignant Syndrome:NMS

■ rare but serious side effect of neuroleptic (antipsychotic) that can be lethal.
■ Idiosyncratic reaction to dopamine antagonists
■ Reported with essentially every D1 or D2 antagonist

Symptoms
 Hyperthermia (41 0c) Muscle rigidity
 Diaphoresis
 changes in level of consciousness ranging from confusion to coma
 Tachycardia
 elevated or labile blood pressure
 Leukocytosis
 laboratory evidence of muscle injury (e.g., elevated CPK

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Other adverse effect

■ Abdominal obesity
■ Atherogenic dyslipidemia (blood fat disorders — high triglycerides, low HDL cholesterol and high
LDL cholesterol)
■ Elevated blood pressure
■ Insulin resistance or glucose intolerance
■ Hormonal effects and sexual dysfunction

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■ Psychosocial intervention
– Social skill training
– Family therapy
– Vocational rehabilitation and supported employment
■ Cognitive behavioral therapy
■ Electroconvulsive therapy
– Catatonic stupor & uncontrolled catatonic excitement
– Acute exacerbations not controlled with drugs
– Risk of suicide, homicide or danger of physical assault

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 Summary

■ Psychosis is break in reality testing such that the person has delusions or hallucinations without
insight.
■ Schizophrenia is heterogeneous syndrome of disorganized thoughts, delusions, hallucinations, and
impaired psychosocial functioning.
■ It has biological and non-biological causes
■ It is a devastating illness with 10% suicidal rate and 50% with long term incapacitation
■ It can be treated by antipyschotic medications, ECT and psychosocial interventions
■ The best method of treatment is combination of drug therapy and psychosocial therapy

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Were you listening?

■ What is the strongest predictor of treatment outcome in first-episode schizophrenia?

■ What are the 4 A’s of the Negative symptoms?
■ Are patients with schizophrenia more likely to be violent?
Refrences

■ DSM Manual
■ Kaplan and Sadock’s synopsis of psychiatry
■ Lecturio
■ Osmosis
■ https://www.youtube.com/watch?v=MU7DNJYHm4o