Schizophrenia and Other Psychotic Disorders

Schizophrenia and Other Psychotic Disordersد.وليد عزيز العميدي
I. SCHIZOPHRENIA
A. Overview
1. Schizophrenia is a chronic, debilitating mental disorder characterized by periods of loss of touch with reality (psychosis); persistent disturbances of thought, behavior, appearance, and speech; abnormal affect; and social withdrawal.
2. Peak age of onset of schizophrenia is 15–25 years for men and 25–35 years for women.
3. Schizophrenia occurs equally in men and women, all cultures, and all ethnic groups studied.
4. The patient shows intact memory capacity; is oriented to person, place, and time; and has a normal level of consciousness (e.g., is alert).
B. Symptoms of schizophrenia can be classified as positive or negative.
1. Positive symptoms are things additional to expected behavior and include delusions, hallucinations, agitation, and talkativeness.
2. Negative symptoms are things missing from expected behavior and include lack of motivation, social withdrawal, flattened affect, cognitive disturbances, poor grooming, and poor (i.e., impoverished) speech content.
3. These classifications can be useful in predicting the effects of antipsychotic medication.
a. Positive symptoms respond well to most traditional and atypical antipsychotic agents.
b. Negative symptoms respond better to atypical than to traditional antipsychotics .
4. Patients with predominantly negative symptoms have more neuroanatomic (see below) and metabolic abnormalities (e.g., decreased cerebral metabolism of glucose) than those with predominantly positive symptoms.
C. Course.
Schizophrenia has three phases: prodromal, active, i.e., psychotic, and residual.
1. Prodromal signs and symptoms occur prior to the first psychotic episode and include avoidance of social activities; physical complaints; and new interest in religion, the occult, or philosophy.
2. In the active phase, the patient loses touch with reality. Disorders of perception, thought content, thought processes, and form of thought
Symptoms of Schizophrenia: Disorders of Perception, Thought Content, Thought Process, and Form of Thought
Disorder of Symptom Definition Example
Perception Illusion



Misperception of real external stimuli


Interpreting the appearance of a coat in a dark closet asa man


Hallucination False sensory perception Hearing voices when alone in a room
Thought content Delusion


False belief not shared by
Others

The feeling of being
followed by the FBI


Idea of reference False belief of being referred
to by others The feeling of being
discussed by ??omeone on
television
Thought
processes Impaired
Abstractionability


Problems discerning the
essential??qualities of objects or relationships



When asked what brought
her to the emergency room, the patient says, "Anambulance"




Magical thinking Belief that thoughts affect the course of events Knocking on wood to
prevent??something bad from happening
Form of thought Loose
Associations




Shift of ideas from one subject to another in an unrelated way

The patient begins to
answer a question about her health and then shifts to a statement about baseball


Neologisms

Inventing new words
The patient refers to her
doctor as a "medocrat"

Tangentiality Getting further away from
the point as speaking
continues The patient begins to
answer a question about her health and ends up talking about her sister s abortion

3. In the residual phase (time period between psychotic episodes), the patient is in touch with reality but does not behave normally. This phase typically is characterized by negative symptoms.
D. Prognosis
1. Schizophrenia usually involves repeated psychotic episodes and a chronic, downhill course over years. The illness often stabilizes in midlife.
2. Suicide is common in patients with schizophrenia. More than 50% attempt suicide (often during post-psychotic depression or when having hallucinations "commanding" them to harm themselves), and 10% of those die in the attempt.
3. The prognosis is better and the suicide risk is lower if the patient is older at onset of illness, is married, has social relationships, is female, has a good employment history, has mood symptoms, has few negative symptoms, and has few relapses.
E. Etiology.
While the etiology of schizophrenia is not known, certain factors have been implicated in its development.
1. Genetic factors
a. Schizophrenia occurs in 1% of the population. Persons with a close genetic relationship to a patient with schizophrenia are more likely than those with a more distant relationship to develop the disorder
The Genetics of Schizophrenia
The general population 1%
Person who has one parent or sibling (or dizygotic twin) with schizophrenia 10%
Person who has two parents with schizophrenia 40%
Monozygotic twin of a person with schizophrenia 50%
b. Markers on many chromosomes including 1, 2, 5, 6, 7, 8, 11, 13, 15, 17, 18, 19, 22, and the X chromosome have been associated with schizophrenia.
2. Other factors
a. The season of birth is related to the incidence of schizophrenia. More people with schizophrenia are born during cold weather months (i.e., January through April in the northern hemisphere, and July through September in the southern hemisphere). One possible explanation for this finding is viral infection of the mother during pregnancy, since such infections occur seasonally.
b. No social or environmental factor causes schizophrenia. However, because patients with schizophrenia tend to drift down the socioeconomic scale as a result of their social deficits (the "downward drift" hypothesis), they are often found in lower socioeconomic groups (e.g., homeless people).
F. Neural pathology
1. Anatomy
a. Abnormalities of the frontal lobes, as evidenced by decreased use of glucose in the frontal lobes on positron emission tomography (PET) scans are seen in the brains of people with schizophrenia.
b. Lateral and third ventricle enlargement, abnormal cerebral symmetry, and changes in brain density also may be present.
c. Decreased volume of limbic structures (e.g., amygdala, hippocampus) is also seen.
2. Neurotransmitter abnormalities
a. The dopamine hypothesis of schizophrenia states that schizophrenia results from excessive dopaminergic activity (e.g., excessive number of dopamine receptors, excessive concentration of dopamine, hypersensitivity of receptors to dopamine). As evidence for this hypothesis, stimulant drugs that increase dopamine availability (e.g., amphetamines and cocaine) can cause psychotic symptoms. Laboratory tests may show elevated levels of homovanillic acid (HVA), a metabolite of dopamine, in the body fluids of patients with schizophrenia .
b. Serotonin hyperactivity is implicated in schizophrenia because hallucinogens that increase serotonin concentrations cause psychotic symptoms, and because some effective antipsychotics, such as clozapine , have anti-serotonergic-2 (SHT2)
activity.
c. Glutamate is implicated in schizophrenia; N-methyl-d-aspartate (NMDA) antagonists (e.g., memantine) are useful in treating some of the neurodegenerative symptoms in patients with schizophrenia.
G. Subtypes.
DSM-IV-TR Subtypes of Schizophrenia
Disorganized :
1- Poor grooming and disheveled personal appearance
2- Inappropriate emotional responses (e.g., silliness)
3- Facial grimacing, mirror gazing
4- Onset before 25 years of age
Catatonic :
1- Stupor or agitation, lack of coherent speech
2- Bizarre posturing (waxy flexibility)
3- Rare since the introduction of antipsychotic agents
Paranoid :
1- Delusions of persecution
2- Better functioning and older age at onset than other subtypes
Undifferentiated : Characteristics of more than one subtype
Residual :
1- At least one previous psychotic episode
2- Subsequent residual symptoms but no current frank psychotic symptoms
H. Differential Diagnosis
1. Medical illnesses that can cause psychotic symptoms, and thus mimic schizophrenia (i.e., psychotic disorder caused by a general medical condition), include neurologic infection, neoplasm, trauma, disease (e.g., Huntington disease, multiple sclerosis), temporal lobe epilepsy, and endocrine disorders (e.g., Cushing syndrome, acute intermittent porphyria).
2. Medications that can cause psychotic symptoms include analgesics, antibiotics, anticholinergics, antihistamines, antineoplastics, cardiac glycosides (e.g., digitalis), and steroid hormones.
3. Psychiatric illnesses other than schizophrenia that may be associated with psychotic symptoms include:
a. Other psychotic disorders (see below).
b. Mood disorders (e.g., the manic phase of bipolar disorder, major depression .
c. Cognitive disorders (e.g., delirium, dementia, and amnestic disorder) .
d. Substance-related disorders .
4. Schizotypal, paranoid, and borderline personality disorders are not characterized by frank psychotic symptoms but have other characteristics of schizophrenia (e.g., odd behavior, avoidance of social relationships).
I. Treatment
1. Pharmacologic treatments for schizophrenia include traditional antipsychotics (dopamine-2 [D2 ]-receptor antagonists) and atypical antipsychotic agents . Because of their better side-effect profiles, the atypical agents are now first-line treatments. Longacting injectable "depot" forms (e.g., haloperidol decanoate) are useful options in patients whose illness leads to noncompliance with medication.
2. Psychological treatments, including individual, family, and group psychotherapy , are useful to provide long-term support and to foster compliance with the drug regimen.
OTHER PSYCHOTIC DISORDERS
A. Overview.
Psychotic disorders are all characterized at some point during their course by a loss of touch with reality. However, the other psychotic disorders do not include all of the criteria required for the diagnosis of schizophrenia

B. Other psychotic disorders include
Disorder Characteristics Prognosis
Schizophrenia Psychotic and residual symptoms
lasting >6 months Lifelong social and occupational
impairment
Brief psychotic disorder Psychotic symptoms lasting >1day
but <1 month; often precipitating
psychosocial factors 50%–80% recover completely
Schizophreniform disorder Psychotic and residual symptoms
lasting 1–6 months 33% recover completely
Schizoaffective disorder Symptoms of a mood disorder
as well as psychotic symptoms Lifelong social and occupational
impairment (somewhat higher
overall level of functioning than in
schizophrenia)
Delusional disorder Fixed, persistent, non-bizarre
delusional system (paranoid
in the persecutory type and
romantic [often with a famous person] in the erotomanic type); few,
if any, other thought disorders 50% recover completely; many
Have relatively normal social and
occupational functioning
Shared psychotic
Disorder (folie à deux) Development of delusions
in a person in a close relationship (e.g., spouse, child) with someone with delusional disorder (the inducer) 10%–40% recover completely
When separated from the inducer