Schizophrenia Spectrum and Other Psychotic Disorders

Schizophrenia Spectrum and Other Psychotic Disorders

Dr. Safeya Alchalabi

Schizophrenia Spectrum and Other Psychotic Disorders

Schizotypal personality disorder
Delusional disorder
Brief psychotic disorder
Schizophreniform disorder
Schizophrenia
Catatonia
Substance/medication induced psychotic disorder
Psychotic disorder due to another medical condition
Other specified schizophrenia spectrum and other psychotic disorder
Unspecified schizophrenia spectrum and other psychotic disorder

Schizophrenia

historical overview
1856Morel coined the term dementia praecox 1868Kahlbaum's katatonia
1868Griesinger's primare Verrcktheit
1869Hecker's Hebephrenie.
1894Sommer's inclusion of deteriorating paranoid syndromes in the concept of dementia.
1896Emil Kraepelin, two major forms of insanity.
The first, manic-depressive insanity,
The second grouped together catatonia, hebephrenia, and the deteriorating paranoid psychoses under the term dementia praecox,


Schizophrenia
Freud's psychoanalytical splitting of the mind (schizophrenia).
1911 Eugen Bleulersimple schizophrenia
1959Kurt Schneider, who described symptoms of first rank in the acute phase of the illness and second rank
1973, the WHO's International Pilot Study of Schizophrenia

Schizophrenia

Schneider's symptoms of first rank
Auditory hallucinations taking the form of one of the following:
thought echo.
third person.
running commentary.
Disorder of thought interference
thought insertion
thought withdrawal
thought broadcasting.
Passivity phenomena (delusion of control)
passivity of affect,
passivity of impulse
passivity of volition
somatic passivity
Delusional perception


Schizophrenia
•
• Type 1 Predominant positive symptoms
• Type 2 Predominant negative symptoms
•
• acute onset
• insidious onset
•
• good premorbid adjustment
• poor premorbid adjustment
•
• good treatment response
• poor treatment response
•
• normal cognition
• impaired cognition
•
• normal brain structure
• structural brain abnormalities (ventricular enlargement)
•
• reversible neurochemical disturbance
• irreversible neuronal loss
•
• excess or a distortion of normal functioning
• decrease or loss of functioning
•
• release phenomena occurring in healthy tissue
• neuronal loss
•
• Formal thought disorder, disorganized behavior, inappropriate affect, delusions, and hallucinations.
• Poverty of thought and speech, impaired volition, blunted affect and anhedonia, and social withdrawal.


Schizophrenia
Aetiological theory
Neurochemical abnormality hypothesis
Neurodevelopmental hypothesis
The disconnection hypothesis

Schizophrenia

Neurochemical abnormality hypothesis
Dopaminergic overactivity.
Glutaminergic hypoactivity.
Serotonergic (5-HT) overactivity.
a-adrenergic overactivity
Gama-aminobutyric acid (GABA) hypoactivity

Schizophrenia

The neurodevelopmental hypothesis
There is an excess of obstetric complications in those who develop the disorder.
Affected subjects have motor and cognitive problems which precede the onset of illness.
Schizophrenic subjects have abnormalities of cerebral structure at 1st presentation.
Schizophrenic subjects have dermatoglyphic and dysmorphic features.
Although the brain is abnormal, gliosis is absent suggesting that differences are possibly acquired in utero.


Schizophrenia
The disconnection hypothesis
Widespread reductions in grey matter in schizophrenia (particularly temporal lobe).
Disorders of memory and frontal lobe function occurring in a background of widespread cognitive abnormalities.
Reduced correlation between frontal and temporal blood flow on specific cognitive tasks.
A reduction in white matter integrity in tracts connecting the frontal and temporal lobes.

Schizophrenia

Environmental factors
The following have been associated with an increased risk of schizophrenia:
Complications of pregnancy, delivery, and the neonatal period
Delayed walking and neurodevelopmental difficulties
Early social services contact and disturbed childhood behavior
Maternal influenza in pregnancy and winter births
Degree of urbanization at birth

Schizophrenia

Social theories
In the 1960s social theories of schizophrenia (e.g. schizophrenogenic mother, marital skew and schism)

Schizophrenia

Diagnosis


DSM-5 of schizophrenia
A. Characteristics of symptoms: two or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
Delusions
Hallucinations
Disorganised speech
Grossly disorganised or catatonic behaviour
Negative symptoms (i.e. affective flattening, alogia, or avolition)

Schizophrenia

B. Social/occupational dysfunction
C. Duration: continuous signs of the disturbance persist for at least 6-months. This 6-month period must include at least one month of symptoms that meet criterion A.

Schizophrenia

Other clinical presentations
Water intoxication
Occurs particularly in patients with chronic schizophrenia. Cause(s) unknown although many have been suggested.
Clinical features Presents with polyuria, hyponatraemia, and polydipsia. May cause confusion, seizures, cerebral and peripheral oedema. May be fatal.
Differential diagnosis Renal failure, syndrome of inappropriate ADH secretion, IDDM/NIDDM
Investigations U&E and plasma osmolality, glucose, haematocrit, 24hr creatinine clearance, renal USS, and specialist referral where appropriate (severe, recurrent, or life-threatening)
Management Restrict oral fluids, review and/or optimise antipsychotic medication.


Schizophrenia
Epidemiology
Incidence 15 new cases per 100000 population.
Male=female, although males tend to have an earlier onset than females (23y vs. 26y) and develop more severe illnesses.
Prevalence
The lifetime risk of schizophrenia is between 15 - 19 per 1000 population.
Fertility
Low fertility in both men and women with schizophrenia.
Mortality
The diagnosis of schizophrenia carries around a 20% reduction in life expectancy
Suicide is the most common cause of premature death in schizophrenia. It accounts for 10-38% of all deaths in schizophrenia.
Risk is probably highest in the year after first presentation.

Schizophrenia

Morbidity
There is significant comorbidity in patients with schizophrenia:
Common medical problems that occur more frequently, e.g. communicable diseases (HIV, HepC, TB), epilepsy, diabetes, arteriosclerosis, IHD.
Rare conditions that co-occur with schizophrenia, e.g. metachromatic leukodystrophy, acute intermittent porphyria, coeliac disease, dysmorphic features (high-arched palate, low-set ears, minor physical abnormalities).
Substance misuse---cannabis, stimulants, and nicotine in particular

Schizophrenia

inheritance
Genetic factors account for the majority of liability to schizophrenia. Heritability estimates range from 60-80%.


• Schizophrenia liability based on affected relatives
• Family member(s) affected
• Risk (approximate)
• Identical twin
• 46%
• One sibling/fraternal twin
• 12-15%
• Both parents
• 40%
• One parent
• 12-15%
• One grandparent
• 6%
• No relatives affected
• 0.5-1%

Brief psychotic disorder (Acute and transient psychotic disorders)

Clinical features
• Sudden onset,
variable presentation (including perplexity, inattention, formal thought disorder, delusions or hallucinations, disorganised or catatonic behaviour),
usually resolving within less than 1 mth.


Brief psychotic disorder (Acute and transient psychotic disorders)
Aetiology
Sometimes these disorders occur in the context of an acute stressor e.g. life events such as bereavement, marriage, unemployment, imprisonment, accident, childbirth, or migration and social isolation.

Brief psychotic disorder (Acute and transient psychotic disorders)

Epidemiology
Associated with certain personality types (e.g. paranoid, borderline, histrionic);
more prevalent in developing nations where, there is a strong emphasis on traditional values

Brief psychotic disorder (Acute and transient psychotic disorders)

Management
Assessment is vital to make the appropriate diagnosis.
Short-term admission may be necessary to provide support, nursing care, and specific assistance with psychosocial stressors.
Where medication is considered, short-term use of antipsychotics/ benzodiazepines may be helpful.
Antidepressants/mood stabilizers may be useful to prevent relapse/ further episodes.

Brief psychotic disorder (Acute and transient psychotic disorders)

Course and prognosis
By definition these disorders are brief and resolve within days, weeks, or month.
Prognosis is better if there is a short interval between onset and full-blown symptoms, (confusion and perplexity, good premorbid social and occupational functioning, absence of blunted or flat affect).
Outcome is better than schizophrenia (both socially and symptomatically).
Relapse is common, with increased mortality and suicide rates compared to the general population.


Schizophreniform disorder
Original term refers to patients with schizophrenic symptoms with a good prognosis.
Now refers to a schizophrenia-like psychosis that fails to fulfill duration criterion for schizophrenia.
Treatment is the same as for an acute episode of schizophrenia.
• Good prognostic signs
Psychotic symptoms appear early in illness,
confusion/perplexity,
good premorbid personality,
absence of blunted/flat affect.

Schizoaffective disorder

Schizophrenia is a disorder in which the symptoms of affective disorder and schizophrenia are present in approximately equal proportion (Schizophrenic and affective symptoms simultaneously present and both are equally prominent).
Major depressive, manic, or mixed episode concurrent with symptoms that meet criterion A for schizophrenia.
2 weeks of delusions and/or hallucinations without prominent mood symptoms.
Symptoms meeting criteria for a mood episode are present for a substantial portion of the active and residual periods.

Schizoaffective disorder

Treatment
As for schizophrenia but treat manic or depressive symptoms as outlined in bipolar disorder Prognosis
Depressive symptoms are more likely to signal a chronic course compared to manic presentations. Good/poor prognostic factors are the same as for schizophrenia.