Schizophrenia, schizotypal and delusional disorders

F20 Schizophrenia
.x0 Continuous
.x3 Episodic remittent
.x4 Incomplete remission
.x5 Complete remission
F21 Schizotypal disorder
F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia
.x0 Without associated acute stress
.x1 With associated acute stress
F24 Induced delusional disorder
F25.1 Schizoaffective disorder, depressive type
F28 Other nonorganic psychotic disorders
F29 Unspecified nonorganic psychosis
B 02 Schizophreniform Disorder
B 04 Delusional Disorder
B 05 Schizoaffective Disorder
B 15 Psychotic Disorder Associated with a Known General
Medical Condition
B 16 Catatonic Disorder Associated with a Known General Medical Condition
B 17 Other Specified Psychotic Disorder
B 18 Unspecified Psychotic Disorder
B 19 Unspecified Catatonic Disorder
ICD-11
• 6A20 Schizophrenia
• 6A24 Delusional disorder
• 6A2Y Other specified schizophrenia or other primary psychotic disorders
• 6A2Z Schizophrenia or other primary psychotic disorders, unspecified
Catatonia
• 6A41 Catatonia induced by psychoactive substances, including medications
• 6A4Z Catatonia, unspecified
and multiple aspects of behavior
– (endogenous) psychosis • hallucinations
• long-term deteriorating course
• hallucinations and delusions
psychosis
• paranoia
for schizophrenia
• it is not split personality, but the presence of schisms between thought, emotion, and behavior
– schisis σχζειν – cleavage
– phrein φρν – mind
– The Four As
– Associations
– Affect
– Autism
– Ambivalence
• Kurt Schneider (1887 – 1967)
He emphasized that in patients who showed no first-rank symptoms, the disorder could be diagnosed
exclusively on the basis of second-rank symptoms and an otherwise typical clinical appearance
Audible thoughts Auditory hallucinations of a person’s voice being spoken aloud
Voices arguing or discussing Auditory hallucinations of two or more voices arguing or discussing, usually about the
person
Auditory hallucinations commenting on a person’s behaviors
Somatic passivity Tactile or visceral hallucinations that are imposed by some external agent; can be
combinations of different somatic hallucinations
Thought withdrawal Sensation of thoughts being actively removed from a person’s mind
Thought insertion Thoughts inserted into a person’s mind by some external agent
Thought broadcasting The sense that a person’s thoughts are experienced as real phenomena by others —the
thoughts are made audible or may be experienced by others through telepathy
Made feelings Feelings that are not a person’s own are imposed on that person by an external agent
Made impulses or drives An impulse for action is imposed on a person by some external agent
Made volitional acts A person’s actions are from and are controlled by an external agent; the person is a
passive participant in the action
Delusional perception A perception that has a unique and idiosyncratic meaning for a person, which
leads to an immediate delusional interpretation
Epidemiology
0
10
20
30
40
50
60
70
15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
vek v rokoch
2
2
4
5
6
6
8
13
17
17
46
48
0 5 10 15 20 25 30 35 40 45 50
Uncle/aunt
Nephew/niece
Cousin
• environmental factors – older age of father
– season of birth
Developmental
stage
Clinical
signs
& symptoms
Normal
Time to the first hospitalisation
(Häfner et al.) P
15 % > 1 month < 1 year
18 % < 1 month
68% 1 year
psychotic pre-phase 1,3 year, median 0,8 year
Meyer-Lindenberg A, Weinberger DR. Neurosci. 2006.
Dopamine theory
• dopaminergic drugs are increasing risk for psychosis
Dopaminergic pathways
1
2
SN/VTA
Symptoms/syndromes of Schizophrenia and Overall Functioning
Occupational
Interpersonal
Mood symptoms:
– negative
– excitement
– disorganization
– depression
– alogia
– anhedonia
– avolition Marder SR, Davis JM, Chouinard G. J Clin Psychiatry. 1997 Dec;58(12):538-46.
Lindenmayer JP, Grochowski S, Hyman RB. Schizophr Res. 1995 Feb;14(3):229-34;
Kay, S.R., Fisbein, A., Opler, L.A.. Schizophr. Bull. 1987, 13, 261– 276
Cognitive symptoms
– Probably correlated to the basic pathophysiological processes
• “cognitive dysmetria” (Andreasen N. et al, 1996)
Pronounced impact on functional outcome
• 20%-60% of variance in functional outcome can be explained by differences in neurocognition – Cognition is better correlated with adaptive functioning
than negative syndrome and a very little or no correlation was found for positive symptoms
Green MF, Kern RS, Braff DL, Mintz J. Schizophr Bull. 2000;26(1):119-36.
Peuskens J, Demily C, Thibaut F. Clin Ther. 2005;27 Suppl A:S25-37.
Andreasen NC et al. Sep 3;93(18):9985-9990.
http://www.matrics.ucla.edu/
• traditionally - better outcome (?)
suicidality, quality of life
2012 Dec;22(12):875-82.
p ri
m a
ry n
o n
”
Tandon R, Jibson MD, Taylor SF, DeQuadro JR. American Psychiatric Press; 1995:109–124.; Buchanan RW. Schizophr
Bull. 2007 Jul;33(4):1013-22.
Diagnosis -ICD 10
• G1. Either at least one of the syndromes, symptoms, and signs listed under (1) below, or at least two of the symptoms and signs listed under (2) should be present for most of the time during an episode of psychotic illness lasting for at least 1 month (or at some time during most of the days).
1. At least one of the following must be present: – thought echo, thought insertion or withdrawal, or thought broadcasting;
– delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;
– hallucinatory voices giving a running commentary on the patient's behavior, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;
– persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g., being able to control the weather, or being in communication with aliens from another world).
2. Or at least two of the following: – persistent hallucinations in any modality, when occurring every day for at least 1 month, when
accompanied by delusions (which may be fleeting or half-formed) without clear affective content, or when accompanied by persistent overvalued ideas;
– neologisms, breaks, or interpolations in the train of thought, resulting in incoherence or irrelevant speech;
– catatonic behavior, such as excitement, posturing or waxy flexibility, negativism, mutism, and stupor;
– “negative” symptoms, such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses (it must be clear that these are not due to depression or to neuroleptic medication).
Diagnosis DSM-IV
B. Social/occupational dysfunction: – one or more major areas of functioning such as work,
interpersonal relations, or self-care are markedly below the level achieved prior to the onset
C. Duration:
• Continuous signs of the disturbance persist for at least 6 months.
– at least 1 month of symptoms (or less if successfully treated) that meet Criterion A
– may include periods of prodromal or residual symptoms • During these prodromal or residual periods, the signs of the
disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
Schizophrenia subtypes
auditory hallucinations.
disorganized speech, disorganized or catatonic
behavior, or flat or inappropriate affect.
• Disorganized type
• disorganized speech
• disorganized behavior
• Catatonic type • motoric immobility as evidenced by catalepsy (including waxy
flexibility) or stupor
• excessive motor activity (that is apparently purposeless and not influenced by external stimuli)
• extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism
• peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing
• echolalia or echopraxia
form of symptoms
A. The general criteria for schizophrenia must be met.
B. Either of the following must be present: 1. definite and sustained flattening or shallowness of affect;
2. definite and sustained incongruity or inappropriateness of affect.
C. Either of the following must be present: 1. behavior that is aimless and disjointed rather than goal-
directed;
2. definite thought disorder, manifesting as speech that is disjointed, rambling, or incoherent.
D. Hallucinations or delusions must not dominate the clinical picture, although they may be present to a mild degree.
ICD 10
Simple schizophrenia A. There is slow but progressive development, over a period of at least 1
year, of all three of the following: 1. a significant and consistent change in the overall quality of some aspects
of personal behavior, manifest as loss of drive and interests, aimlessness, idleness, a selfabsorbed attitude, and social withdrawal;
2. gradual appearance and deepening of “negative” symptoms such as marked apathy, paucity of speech, underactivity, blunting of affect, passivity and lack of initiative, and poor nonverbal communication (by facial expression, eye contact, voice modulation, and posture);
3. marked decline in social, scholastic, or occupational performance.
B. At no time are there any of the symptoms referred to in criterion G1 for general schizophrenia, nor are there hallucinations or well-formed delusions of any kind; i.e., the individual must never have met the criteria for any other type of schizophrenia or for any other psychotic disorder.
C. There is no evidence of dementia or any other organic mental disorder.
Treatment of schizophrenia
Treatment of schizophrenia
the first episode
– often life-long treatment
brain ??
• Mood disorder symptoms (especially depressive disorders) or affective disorders in family history
• Married, good social support system
• Positive symptoms
• Young onset
• Bad family/social support background
Good Poor
F20 Schizophrenia
.x0 Continuous
.x3 Episodic remittent
.x4 Incomplete remission
.x5 Complete remission
F21 Schizotypal disorder
F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia
.x0 Without associated acute stress
.x1 With associated acute stress
F24 Induced delusional disorder
F25.1 Schizoaffective disorder, depressive type
F28 Other nonorganic psychotic disorders
F29 Unspecified nonorganic psychosis
• pervasive pattern of social and interpersonal deficits
• constricted affectivity
• involvement in paranormal phenomena – not clearly “dereistic”, has influence of behavior
• e.g. to wear sun glasses during the night, because of space radiation
• complicated, unusual construction of speech/phrasing – “pseudophilosophy”, “unproductive vague speech”,
– specific/odd argumentation
• strange clothing – outside of trends or socially acceptable norms
• inability to understand jokes, teasing remarks, metaphors
• can be transient psychotic experience like illusion, depersonalization
• differential diagnosis from personality disorders (schizoid, paranoid) – marked eccentricity or oddness
• she/will not change odd clothing because of dress code in company
Delusional Disorder (Paranoia) • Delusions
– A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes
• non-bizarre (or not so bizarre as in schizophrenia)
– may be systematic and stable
• function could not be disturbed outside of delusional system
• Delusions of
– delusions of jealousy
– delusion of pregnancy (pseudocyesis)
• erotomania, Clerembault`s syndrome
• if some hallucinations, they are not prominent or hardly distinguished from disturbance of thinking (like in
prasitosis)
• personality, behavior and emotional reaction can be normal outside of delusional content
• sometimes the crucial event - change in life situation present at the beginning
• must last at least 3 months
F23 Acute and transient psychotic disorders
In DSM-5 Brief Psychotic Disorder
F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia
F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
• acute onset = ≤ 2 weeks – specify if less than 48 hours
• psychoreactive, toxic for differential diagnosis
• not longer prodromal phase !! – remember schizophrenia – symptoms rapidly, both in nature and intensity
– duration of the episode ≤ 3 months = if more, the diagnosis should be changed
» most commonly few days to 1 month
• perplexity/qualitative change of consciousness – but not “organic” reason
• dg. often used for first episode of schizophrenia – reasons mainly more social
• patients with recurrent episodes – is it schizophrenia? - cycloid psychoses
Shared Psychotic Disorder
(Induced Delusional disorder)
• A delusion develops in an individual in the context of a close relationship with another person(s), who has an already-established delusion. – often isolated from society
• The delusion is similar in content to that of the person who already has the established delusion.
Schizoaffective Disorder F25.0 Schizoaffective disorder, manic type F25.1 Schizoaffective disorder, depressive type F25.2 Schizoaffective disorder, mixed type
Difference from schizophrenia: • cyclic course • affective disturbance as the condition, but usually no flat affect
! • better prognosis than for schizophrenia, worse than for mood
disorders
During the same period of illness, there have been delusions or
hallucinations for at least 2 weeks in the absence of prominent
mood symptoms.
• DSM-5 requires that “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”
• Clinical consequence
antidepressants)
Paraphrenia
– more common in women
– spectrum of delusions and hallucinations • erotic type – like touches, rapes, erotomanic
delusions