Bule Hora University

Institute of health
department of psychiatry
Schizophrenia and other psychotic disorders
By: Abdirezak B. (MSc in mental health)
Session outline

• Introduction to psychosis

• Brief history of Mental illness including Schizophrenia

• Epidemiology and etiology of psychotic spectrum disorders

• Diagnostic criteria of psychotic spectrum disorders

• Management of patients with psychotic spectrum disorders

Introduction to psychosis

• Psychosis is a difficult term to define and is frequently misused, not

only in the newspapers and movies and on television, but
unfortunately among mental health professionals as well.

• Stigma and fear surround the concept of psychosis

• long-standing myths of "mental illness," including "psychotic killers,"

"psychotic rage," and the equivalence of "psychotic" with the
pejorative term "crazy."
• There is perhaps no area of psychiatry where misconceptions are
greater than in the area of psychotic illnesses.

• Psychosis is a syndrome, which is a mixture of symptoms that can be

associated with many different psychiatric disorders.

• At a minimum, psychosis means delusions and hallucinations.

• psychosis can be considered to be a set of symptoms in which a
person's mental capacity, affective response, and capacity to recognize
reality, communicate, and relate to others are impaired.

• Psychotic disorders have psychotic symptoms as their defining

features, but there are other disorders in which psychotic symptoms
may be present.
• Those disorders that require the presence of psychosis as a defining
feature of the diagnosis include schizophrenia, substance-induced
psychotic disorder, schizophreniform disorder, schizoaffective disorder,
delusional disorder, brief psychotic disorder, shared psychotic disorder,
and psychotic disorder due to a GMC.

• Disorders that may or may not have psychotic symptoms as an

associated feature include mania and depression, cognitive disorders etc.
 Brief history of MI

• Early man (since 5000 BCE) widely believed that MI is caused by

supernatural phenomena
 spiritual or demonic possession
 Sorcery
 the evil eye
 an angry deity
 Sin (God’s punishment for committing sin)
Brief history of MI

• Hippocrates (Between the 5th and 3rd centuries BCE),

 Denied supernatural causes of MI
 stemmed from natural occurrences in the human body & brain
 MI was due to disturbances of the four essential fluids of the
human body—blood, phlegm, bile, and black bile
 By 790s CE: 1st mental hospital in Baghdad established
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 History of Schizophrenia
• The illness has been described in seers, Prophets, witches and
devils.

• Was not considered as human brain diseases until 19th century

• The word schizophrenia is less than 100 years old, but the
illness had probably accompanied mankind through its
history.
 Schizophrenia
• What is schizophrenia?
– Extremely complex mental disorder and it is probably many
illnesses masquerading as one (Rays of Hope,2003)
– Most dramatic and tragic manifestation of mental illness known to
mankind (Kaplan & Sadock, 2009)
– A clinical syndrome of variable, but profoundly disruptive,
psychopathology that involves cognition, emotion, perception,
and other aspects of behavior (synopsis of psychiatry 10th edition)
 Schizophrenia …
– A severe mental disorder, characterized by profound
disruptions in thinking, affecting language, perception,
and the sense of self (WHO)
A chronic, severe, and disabling brain disorder that
affects thinking, language, cognition, emotion, perception,
behavior and functions…
 Epidemiology

• Life time prevalence=1%

• M:F=1
• Ages of onset
• 10 - 25 years (Male peak age); > 50% have 1st hospitalization
by age 25
• 25 - 35 years (Female peak age); ~33% have 1st
hospitalization by age 25
• 3-10% schizophrenia after age 40 yrs in women
• Late onset (age > 45 years), early onset (<12 years)
• ~90% of schizophrenic pts are b/n 15-55 yrs
• Onset before 10 and after 60 years is rare
 Courses & onset of schizophrenia
• Onset: Acute vs insidious(gradual)

• Course of illness:
• Prodromal phase
• Active phase
• Residual phase
Diagnostic-Criteria-DSM-5
• B: Social, personal &occupational dysfunction

• C: Continuous signs for 6 months, at least 1 month of symptoms

• D: Schizoaffective and mood disorder exclusion

• E: Substance/general medical condition exclusion

• F: Relationship to ASD or communication problems of childhood

onset (delusion or hallucination present for 01 month &fulfilling DX
criteria of schizophrenia
• Specifiers
• First episode, currently in acute episode
• First episode, currently in partial remission
• First episode, currently in full remission
• Multiple episodes, currently in acute episode
• Multiple episodes, currently in partial remission
• Multiple episodes, currently in full remission
• Continuous
• Unspecified
• With catatonia
• Severity rating (last 7days) of schizophrenic symptoms from 0-not
presentpresent &severe
 Types of Schizophrenia
• Schizophrenia
• Paranoid
• Preoccupation with delusions or frequent auditory
hallucinations
• No evidence/ non prominent of marked disorganized
speech, disorganized or catatonic behavior, flat or
inappropriate affect.
• Disorganized
• Disorganized speech
• Disorganized behavior
• Flat or inappropriate affect
• No evidence of catatonia
 Types of Schizophrenia
• Catatonic: At least two of the following:
• immobile body or stupor,
• excessive motor activity that is purposeless and unrelated to outside
stimuli,
• Extreme negativism or mutism
• Assumption of bizarre postures, or stereotyped movements or
mannerisms
• Echolalia or echopraxia…
• Undifferentiated
• Symptoms that do not meet the criteria for Paranoid, Disorganized or
Catatonic Schizophrenia
• Residual
• Absence of delusions, hallucinations, disorganized speech, and
grossly disorganized or catatonic behavior
 Etiology of Schizophrenia

• The etiology and pathogenesis of schizophrenia is not well

known

• Causes are multi-factorial:

• Internal factors – genetic, inborn, biochemical
• External factors – trauma, infection of CNS, stress
• Psycho-Social factors
 Etiology of schizophrenia…
• Neuropathology:
– Cerebral Ventricles
– Limbic System
– Prefrontal Cortex
– Basal Ganglia and Cerebellum
 Etiology of schizophrenia…
• Biochemical Factors

• Different biochemical factors contribute but the mechanism is not

clear or indirect for most
• Dopamine

• Serotonin

• Norepinephrine

• γ-aminobutyric acid (GABA)

• Glutamate

• Acetylcholine and Nicotine

Treatment of schizophrenia
Schizophrenia treatment …
• Common needs of people with schizophrenia
• Symptom control
• Social skills
• Housing
• Income
• Work
• Treatment of comorbid conditions
Schizophrenia treatment …
• Challenges
• Stigma
• Impaired “insight”– no agreement on problem
• Treatment “compliance”
• Substance abuse very common
• Violence risk
• Suicide risk
• Medical problems common, often unrecognized
Management phase
• Acute phase:
- calming the pt and alleviating the most severe symptoms
- Mng’t of V/S, S/E, input and output
- Identifying and tx triggering fact. Of the onset
- Quickly restoring optimum functioning
Stabilization phase :
-continuing therapeutic agent to inc. response, to decrease relapse of
symptoms
-To Mng’t of S/E
-To favour the recovery process
Maintenance phase: to maintain remission, optimum functions and to
Mng S/E
 PSYCHOSOCIAL THERAPIES

• Psycho education
• Social Skills Training
• Family-Oriented Therapies
• Case Management
• Assertive Community Treatment
• Group Therapy
• Cognitive Behavioral Therapy
• Individual Psychotherapy
• Vocational and art therapy
• Rehablitaion
 2. Delusional Disorder

• Delusions :fixed beliefs that are not amenable to change in

light of conflicting evidence
• Content include a variety of themes

• Persecutory delusions:
– Belief that one is going to be harmed, harassed, and so
forth by an individual, organization, or other group) are
most common
 Delusional Disorder
• Referential delusions
• belief that certain gestures, comments, environmental
cues, and so forth are directed at oneself) are also
common.
• Grandiose delusions
• when an individual believes that he or she has
exceptional abilities, wealth, or fame)
• Érotomanie delusions
• When an individual believes falsely that another person
is in love with him or her.
 Delusional Disorder
• Nihilistic delusions:
• involve the conviction that a major catastrophe will
occur, and somatic delusions focus on preoccupations
regarding health and organ function
• Bizarre vs non- bizarre
– Bizarre: clearly implausible derive from ordinary life
experiences
– Non-bizzare: plausible
• Mood congruent vs mood incongruent
 Delusional Disorder-diagnosis
A. One (or more) delusions with a duration of 1 month or longer

B. Criterion A for schizophrenia has never been met

C. Functioning is not markedly impaired, and behavior is not obviously bizarre

or odd.

D. If manic or major depressive episodes have occurred, these have been brief
relative to the duration of the delusional periods.

E. Not due to substance, medical condition and other mental disorders

• Use type, course and severity specifiers

Delusional Disorder..

• Prevalence : lifetime ~ 0.2%

• Social, marital, or work problems due to delusional beliefs of

delusional disorders can be associated features Supporting diagnosis

• Functionality is circumscribed to only delusional beliefs

Delusional Disorder…
• Rule out: DDX
• Obsessive-compulsive and related disorders (body
dysmorphic disorders)
• Delirium, major neurocognitive disorder, psychotic disorder
due to another medical condition, and substance/medication-
induced psychotic disorder
• Schizophrenia and schizophreniform disorder
• Depressive and bipolar disorders and schizoaffective
disorder.
Delusional Disorder-treatment
• Pharmacotherapy-anti-psychotics
• Psycho-therapy
 3. Brief Psychotic Disorder

• Sudden onset (non-psychotic –psychotic within 2wks) of at least

one the positive psychotic symptoms

• Disturbance lasts at least 1 day but less than 1 month then full
functionality

• Occur mostly,among younger patients (20s and 30s) years

• Biological or psychological vulnerability (borderline, schizoid,

schizotypal, or paranoid personalities)
• Almost always preceded by precipitating factors

• Precipitating Stressors
• Events that cause a significant emotional upset
• Example: loss of loved one, accident…
 Diagnostic Criteria for Brief Psychotic Disorder

A. Presence of one (or more) of the following symptoms:

A. delusions
B. hallucinations
C. disorganized speech (e.g., frequent derailment or incoherence)
D. grossly disorganized or catatonic behavior
B. Duration of an episode of the disturbance is at least 1 day but less
than 1 month
C. Disorders is not due to other mental disorder/medical
condition/substance
• Specifier (stressor)
• With marked stressor
• Without marked stressor
• Post partum onset

• With catatonia

• Severity
Brief psychotic disorder
• Facts and Tips about Brief Psychotic Disorder
• Brief psychotic disorder occurs soon after and frequently in response to a trauma or
major stress, for example the death of a love one, relationship breakdown, an
accident or assault, or a natural disaster.
• Brief psychotic disorder by means noticeable stressor also known brief reactive
psychosis.
• Brief psychotic disorder occurs in women, usually within 4 weeks of having a baby.
 Brief psychotic disorder
DDX
• Schizophreniform disorder
• Schizophrenia
• Subsatnce induced psychotic disorders
• Schizoaffective disorders
• Psychotic disorders due to GMC
• Substance intoxication/withdrawal
• Delrium
• Malingering
 Brief psychotic disorder
• Treatment
• Hospitalization
• Pharmacology treatment
• Anti-psychotics
• Benzodiazepines
• Psycho-therapy
• Prognosis
• 50 -80% of all patients have no further major psychiatric
illness
4. Schizophreniform Disorders
• Similar to schizophrenia, except that its symptoms last at least
1 month but less than 6 months

• A lifetime prevalence =0.2 % & 1-year prevalence =0.1%

• Good outcome, indicated that the disorder probably has

similarities to the episodic nature of mood disorders

• Have more affective symptoms (especially mania) and a better

outcome than patients with schizophrenia
 Schizophreniform disorder

• Clinical features
• Rapid onset and lacks a long prodromal phase
• No Progressive decline in social and occupational
functioning
• Negative symptoms-uncommon
• Pts return to their baseline state within 6 months
 Criteria for Schizophreniform disorder
• 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
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms
Criteria cont’d
• Duration : > 1month & < 6 month
• Other mental disorders & GMCs ruled out
• Disorder is not due to substance use
• Specifiers:
• with good prognostic feature vs without good prognostic features
• With catatonia
• severity
DDx
• Schizophrenia
• Substance induced psychotic disorders
• Schizoaffective disorders
• Mood disorders with psychotic feature
• Course and Prognosis
• 60 -80% progress to schizophrenia
• 20 – 40% will have 2nd & 3r episodeschizophrenia
• Few may have single episode normaly functional
• Treatment
• Hospitalization
• Anti-psychotic Rx= 3-6 month
• 75% of pts. Respond to antipsychotic with 8 days
• ECT if with catatonic feature
5. Schizoaffective disorder
• A disorder with symptoms of both schizophrenia and mood disorders
• Onset of symptoms is sudden and often occurred in adolescence
• Pts. Have good pre-morbid level of function
• Life time prevalence 0.5 - 0.8%
• Depressive type=older age & bipolar type= young adult
• More in women than in men
Schizoaffective disorder
Diagnosis
A. An uninterrupted period of illness during which there is a major mood episode
(major depressive or manic) concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1 : Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood
episode (depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the
majority of the total duration of the active and residual portions of the illness
D. Disturbance is not due to: substance & GMC
Schizoaffective disorder
Specifiers
• Bipolar type:
– This subtype applies if a manic episode is part of the presentation.
Major depressive episodes may also occur
• Depressive type:
– This subtype applies if only major depressive episodes are part of the
presentation.
• With catatonia
Schizoaffective disorder
Treatment
• Anti-psychotics
• Mood stabilizers
• Anti-depressants =with caution
Postpartum psychosis
Thanks