Session 8 Schizophrenia And Related Disorders

Front 1

Schizophrenia Basic Features

Back 1

Hallmark is a significant loss of contact with reality referred to as psychosis.
Should be referred to as “the schizophrenias”
Clinical presentation:
in perception
in thinking
in actions
in sense of self
in manner of relating to others

Front 2

Schizophrenia Basic Epidemiology

Back 2

Lifetime morbid risk is 1.0% of people born today to age 55.
Average age of onset for men is 25 y/o
Average age of onset for women is 29 y/o
Vast majority of cases begin in late adolescence and early adulthood.
Origins of construct: 1810 John Haslam in London, England though Emil Kreapelin in Germany in 1896 documented the traditional symptoms.

Front 3

Schizophrenia in the DSM-5 Basic Criteria (clinical elements)

Back 3

Schizophrenia-DSM5 clinical elements
Two or more for at least one-month
Delusions
Hallucinations
Disorganized thinking/speech
Grossly disorganized or abnormal behavior (inc. catatonic)
Negative symptoms (Comer p.433 Table 14.1)
Social/Occupation dysfunction
Duration – at least six months
NOTE:
Schizoaffective D/o and Mood D/o exclusion
Substance Abuse/General Medical condition exclusion
Relationship to PDD – only if prominent delusions/hallucinations

Front 4

Schizophrenia Positive Type 1 Symptoms

Back 4

pathological excesses, bizarre editions to someone's behavior.
Positive
Hallucinations
Delusions
Disorganized thinking and speech
Heightened perception
Inappropriate affect
Sudden onset
Variable course
Type I (above plus)
Good response to drugs
Limbic system abnormalities

Front 5

Schizophrenia -Negative/Type II symptoms

Back 5

pathological deficits, characteristics that are lacking in an individuals
Negative
Emotional flattening
Poverty of speech
Flat affect, blunted, restricted
Apathy (avolition)
Significant cognitive impairment
Insidious onset
Chronic course
Type II
Uncertain response to drugs
Frontal lobe abnormalities
Enlarged brain ventricles

Front 6

Schizophrenia-subtypes:
Paranoid

Back 6

History of suspiciousness in interpersonal relationships
Persecutory delusions most common
Delusions of grandeur also common
Tend to function as a higher level overall

Front 7

Schizophrenia-subtypes:
Disorganized

Back 7

Early age onset, disorganized speech. behavior and inappropriate affect

Front 8

Schizophrenia-subtypes:
catatonic

Back 8

Pronounced motor signs –excited or stuporous, highly suggested and often mimic speech/behavior

Front 9

schizophrenia subtypes:
Undifferentiated type

Back 9

unclear clinical presentation

Front 10

schizophrenia subtypes:
residual type

Back 10

People who have suffered an episode but are now positive symptom free, display negative symptoms

Front 11

: delusional

Back 11

Give voice and act on absurd beliefs

Front 12

psychotic

Back 12

sudden onset of psychotic symptoms and grossly disorganized behavior

Front 13

schizophreniform

Back 13

Schizophrenia –like psychosis lasting 1 month to less than six months

Front 14

schizophrenia

Back 14

Schizophrenia –like psychosis lasting 1 month to less than six months

Front 15

schizoaffective

Back 15

symptoms of both schizophrenia and severe affective disorder

Front 16

Delusional Disorder features;

Back 16

Sx: Presence of one or more delusions that persist for at east one month.
Prevalence: Lifetime prevalence = 0.2% with the most common subtype being persecutory. Global functioning is better thlan schizophrenia.
Gender: Jealous subtype most common in males . Otherwise no gender difference observed.
Misc elements: subtypes
Erotomania type
Grandiose type
Jealous type
Persecutory type
Somatic type

Front 17

Delusional Disorder Diagnostic Criteria

Back 17

A. Presence of one (or more) delusions with a duration of one month or longer.
B. Criterion B for Schizophrenia has never been met.
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously bizarre or odd.
D. If manic or depressive episodes have occurred , these have been brief relative to the duration of the delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance and is not better explained by another mental disorder.

Front 18

Delusional Disorders Specifiers:

Back 18

Erotomania type
Grandiose type
Jealous type
Persucutory type
Somatic type
Mixed type
Unspecified type.
Specify if:
With bizarre content – delusions are clearly implausible.
Specify if: after one year course of the disorder
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

Front 19

Brief Psychotic features disorder:

Back 19

A disturbance that involves the sudden onset (within a two week period) of at least one of the positive symptoms. The episode duration is one day to less than one month.1
Prevalence: In the US first onset of psychotic cases = 9%
Gender: Females 2:1
Misc elements: Despite a high relapse rate, outcomes remains excellent in terms of social functioning and symptomology.

Front 20

Brief psychotic disorder: diagnostic criteria

Back 20

A. Presence of one (or more) of the following symptoms. At least one must be 1, 2 or 3.
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
B. Duration of the disturbance is at least one day but less than one month; with eventual return to premorbid functioning.
C. Disturbance in not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder, is not attributable to a substance use or another medical condition.

Front 21

Brief psychotic disorder Specifiers:

Back 21

Specify if:
With marked stressor(s): stressors recognized as stressful by most people
Without marked stressor(s): stressors not recognized as stressful by most people
With postpartum onset: onset during pregnancy or within four weeks postpartum

Specify if:
With catatonia: meets criteria for catatonia (pp. 119-120)
Coding Note: Use additional code 293.89 (F06.1) catatonia associated with brief psychotic disorder to indicate the presence of the comorbid catatonia.
Specify current severity
Severity is clinician rated. Recommend use of the “Clinician-Rated Dimensions of Psychosis Symptom Severity” in chapter on Assessments and online at www.dsm5.org

Front 22

Schizophreniform Disorder Features

Back 22

Sx: Symptoms of Schizophreniform are identical to schizophrenia with the difference being in the duration which is greater than one month and less than six months.
Prevalence: Incidence and development is similar that seen in Schizophrenia. One-third of individual diagnosed with Schizophreniform recover within the six month period and suffer no further mental illness. The remaining two-thirds go on to develop schizophrenia or schizoaffective disorder.
Misc elements:

Front 23

Schizophreniform Disorder: Diagnostic Criteria Part A,B

Back 23

A. Two (or more) of the following, each resent for a significant portion of time during a one month period (or less if successfully treated). At least one must be 1, 2 or 3.
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
B. An episode lasts at one month but less than six months. When the diagnosis must be made without waiting for recovery, it must be “provisional”.1

Front 24

Schizophreniform Disorder: Diagnostic Criteria Part C,D

Back 24

C. Schizoaffective disorder and depressive and bipolar disorder with psychotic features have been ruled out.2
D. The disturbance is not attributable to the physiological effects of a substance or belter explained by another mental disorder.

Front 25

Schizophreniform Disorder – Specifiers

Back 25

Specify if:
with good prognostic features: apply if at least two of the following are present –
Onset of prominent psychotic feature within four weeks
Confusion or perplexity
Good premorbid functioning
Absence of blunted or flat affect
without good prognostic features: apply if two or more of the above prognostic feature have not been present
Specify if:
With catatonia: meets criteria for catatonia (pp. 119-120)
Coding Note: Use additional code 293.89 (F06.1) catatonia associated with brief psychotic disorder to indicate the presence of the comorbid catatonia.
Specify current severity:
Severity is clinician rated. Recommend use of the “Clinician-Rated Dimensions of Psychosis Symptom Severity” in chapter on Assessments and online at www.dsm5.org

Front 26

Schizophrenia Disorder features

Back 26

Sx: Involve a range of cognitive, behavioral and emotional dysfunctions with no single symptom solely characteristic of the disease. Symptoms must be present for a one month period or longer. At least one must be: delusions, hallucination or disorganized speech.
Prevalence: lifetime prevalence = 0.3% - 0.7%. Onset age is typically between late teens and mid-30’s. Onset prior to adolescence is rare and later for females.
Gender: Sex ratios differ. Males – Negative symptoms and longer duration with poorer outcomes. Females experience more affect laden and more psychotic symptoms compared to males.
Morbidity: High substance use comorbid with over 50% of those diagnosed users of tobacco products. Anxiety disorders with elevated rates of OCD and Panic Disorder.
Misc elements: People diagnosed with schizophrenia experience reduced life expectancy due to associated medical conditions

Front 27

Schizophrenia Disorder Diagnostic Criteria

Back 27

A. Two (or more) of the following, each present for a significant portion of time during a one month period (or less if successfully treated). At least one must be 1, 2 or 3.
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
B. For a significant portion of time since onset, level of functioning in one or more areas is markedly below previously achieved levels.
C. Continuous signs of disturbance persist of at least six months including at least one month of symptoms meeting Criteria A.
D. Schizoaffective disorder and depressive and bipolar disorder with psychotic features have been ruled out.
E. The disturbance is not attributable to the physiological effects of a substance or belter explained by another mental disorder.
F. If history of autism spectrum, diagnosis only made with prominent delusions or hallucinations.

Front 28

Schizoaffective Disorder Features

Back 28

Major Mood Disorder (Uni- or Bi-) criteria met
And exhibit at least two major symptoms of schizophrenia
During at least two weeks of illness hallucinations and/or must occur in absence of mood symptoms
Must meet mood disorder criteria for substantial period of the illness.

Front 29

Schizoaffective Disorder Features

Back 29

Sx: Both symptoms of psychosis and/or schizophrenia are present with symptoms of major depressive episode. Psychotic feature, delusions or hallucinations must present for at least a two week period in which there is an absence of a major mood episode.
Prevalence: Approximately one-third as common as schizophrenia = 0.3%. Typical onset age is early adulthood through onset can occur anyway between adolescence through late life.
Gender: Incidence is higher in females than males.
Morbidity: Especially with substance use disorders and anxiety disorders. Incidence of medical conditions is higher with lower life expectancy similar to schizophrenia

Front 30

Schizoaffective Disorder – Diagnostic criteria

Back 30

A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of Schizophrenia)1.
NOTE: The major depressive episode must include Criterion A1: Depressed mood
B. Delusional or hallucinations for two or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime 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 attributable to the physiological effects of a substance or belter explained by another mental disorder.

Front 31

Schizoaffective Disorder – Specifiers

Back 31

Specify if:
295.70 (F25.0) Bipolar Type: Applies if a manic episode part of the presentation. A major depressive episode may also occur.
295.70 (F25.0) Depressive Type: Applies if only a major depressive episode is part of the presentation.
Specify if:
With catatonia: meets criteria for catatonia (pp. 119-120)
Coding Note: Use additional code 293.89 (F06.1) catatonia associated with brief psychotic disorder to indicate the presence of the comorbid catatonia.
Specify if: after one year course of the disorder
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
Specify current severity:
Severity is clinician rated.

Front 32

Schizophrenia – causes

Back 32

Genetics:
Environmental:
Familial:
Biochemical – dopamine hypothesis ( evidenced by the phenothiazines) relatively small temporal and frontal lobes and
structural abnormalities
Prenatal issues – viruses

Front 33

Schizophrenia – Treatment/Clinical Outcomes

Back 33

16% of patients recover and need no f/u treatment

12% of patients require long-term institutionalization

Approximately one third of patients display continued signs of illness, usually with prominent negative symptoms

Treatment:
Conventional antipsychotic-side affects (neuroleptics)
Thorazine and Haldol
Pyramydal side affects – involves Parkinson’s-like movements and tardive dyskinesia (involves movement lips, tongue, hands and neck)
Novel antipsychotic fewer side affects
Risperadal, Zyprexa, Seroquel and Geodon

Front 34

Schizophrenia – Treatment/Clinical Outcomes
Treatment:

Back 34

Conventional antipsychotic-side affects (neuroleptics)
Thorazine and Haldol
Pyramydal side affects – invol Parkinson’s-like movements and tardive dyskinesia (invol movement lips, tongue, hands and neck)
Novel antipsychotic fewer side affects
Risperadal, Zyprexa, Seroquel and Geodon
Psychosocial therapy
Family therapy: relapse rates are lower
Case management: helps marshal community resources, reduces hospitalizations
Social-skills training: results are mixed, but appears helpful
Cognitive-behavioral therapy: CBT shows decreases in hallucinations and delusions through restructuring of cognitions, needs Rx therapy to work
Individual treatment: coping strategies and techniques