Psychotic Disorders

PSYCHOSIS/PSYCHOTIC

PSYCHOSIS/PSYCHOTIC

• Major personality disorder characterized by mental emotional disruptions.

• Much more severe than neurosis – often impairing and debilitating the affected individual

NEUROTIC/NEUROSIS

• Mild mental disorder not arising from organic diseases;

• Instead, it can occur from stress, depression, or anxiety

• Possible for us to experience

Shared Features of the Psychotic Disorder DSM Class

• These disorders constitute a significant distortion in the perception of reality with recurrent, episodic, or persistent features (DSM-IV-TR,p.)

• The disorders are characterized by positive symptoms and negative symptoms.

• Impairment in capacity to reason, speak, behave rationally or spontaneously 

• Impairment in capacity to respond spontaneously with appropriate affect and motivation.

Positive Symptoms

• characterizing onset or relapse and including hallucinations, delusions, and/or thought disorder

• Hallucinations

• Delusions

  
  

Negative Symptoms

• absence/loss of drive, motivation, emotion, self-care, and other executive functions

• Affective flattening

• Alogia

• Blocking

• Poor grooming

• Lack of motivation

• Anhedonia

• Social withdrawal

Alogia

• is a process of poor thinking inferred from speech and language usage

Anhedonia

• is the inability to feel pleasure

Hallucinations

• are defined as perceptions that occur in the absence of a corresponding external sensory stimulus.

• things that are sensed but not real

Illusions

• are misinterpretations of a true sensory stimulus

• beliefs that are not real or correct.

SCHIZOPHRENIA

• Schizophrenia is a serious mental disorder in which people interpret reality abnormally

• Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning and can be disabling.

• People with schizophrenia require lifelong treatment

• Early treatment may help get symptoms under control before serious complications develop and may help improve the long-term outlook.

EPIDEMIOLOGY OF SCHIZOPHRENIA - GENDER AND AGE

• women = men

• Onset: men is earlier than women

• More males are admitted before 25 y.o

• Peak age onset: men = 10 - 25 y.o; women = 25 - 35 y.o

• 3 - 10 % women present w/ disease onset after age 40

• 90% in treatment = 15 - 55 y.o

• Extremely rare : before age 10 or after 60 

• Men impaired by negative symptoms

• Outcome: women = better than men 

• Late - onset schizophrenia = onset occurs after age 45

CAUSES - GENETIC INFLUENCES - SCHIZOPHRENIA

• Identical twin affected - 50%

• Fraternal twin affected - 15%

• Both parents affected - 35%

• One parent affected - 15%

• Brother or sister affected - 10%

• No affected relative - 1%

SIGNS & SYMPTOMS - SCHIZOPHRENIA

• Alterations in personal relationships

• Alterations of activity

• Altered perception

• Alterations of thought 

• Distorted thinking

• Altered consciousness

• Alterations of affect

PRODROMAL SYMPTOMS

• signs before manifesting the condition

PRODROMAL SYMPTOMS OF SCHIZOPHRENIA

• Medical term for early signs or symptoms of an illness or health problem that appear before the major signs or symptoms start

• A month or a year before the onset

• Deterioration in previous functioning, withdrawn from others, lonely, depressed

• Vague plan for the future

• Neurotic symptoms ie. anxiety, phobia, difficulty in concentration, misinterpretation

• Feelings of rejection, lack of self-respect

HALLUCINATIONS (alterations in perception, behavior)

• auditory, visual, olfactory, gustatory, tactile

BIZARRE BEHAVIOR (alterations in perception, behavior)

• extreme motor agitation, stereotyped behavior, automatic obedience, waxy flexibility, stupor, negativism

AGITATED BEHAVIOR (alterations in perception, behavior)

• poor impulse contro

OBJECTIVE SIGNS

• Observe directly

• Altered relationships, hygiene, social skills, communication, and psychomotor activity

• Frightens others may lead to involuntary psychiatric intervention

DIAGNOSIS - DSM-IV-IR

Characteristic symptoms

• Must persist for at least 6 mos.

• 2 or more following each present for a significant portion of time during a 1 – month period

• Delusions

• Hallucinations

• Disorganized speech

• Grossly disorganized or catatonic behavior

• Negative symptoms

• Schizoaffective d/o or mood d/o must be absent

  • Schizoaffective

Schizoaffective

• combination of schizophrenia and mood disorders (presence of depression)

Subtypes of DSM-IV-TR

• PARANOID

• DISORGANIZED

• CATATONIC

• UNDIFFERENTIATED

• RESIDUAL

ICD - 10 (9 Subtypes)

• paranoid, hebephrenia, catatonic, undifferentiated, postschizophrenic depression, residual, simple, other schizophrenia, unspecified

PARANOID

• Preoccupation with one or more delusions or frequent auditory hallucinations

• Presence of delusions of persecution or grandeur

• First episode of illness at an older age

• Occurs in the late 20s and 30s have usually established a social help

• Less regression of their mental faculties, emotional responses

• Tense

• Suspicious

• Guarded

• Reserved

• Hostile or aggressive

• Occasionally conduct themselves adequately in social situations

• Intelligence tends to remain intact

DISORGANIZED

• “Hebephrenic”

• Marked regression to primitive

• Disinhibited

• Disorganized speech

• Disorganized behavior

• Flat or inappropriate affect

• The criteria are not met for catatonic type

• Onset: early before the age of 25

• Active but aimless, nonconstructive manner

• Thought disorder = high

• Contact with reality = poor

• Personal appearance: dilapidated (wala na ligo ligo)

• Social behavior and emotional responses = inappropriate

• Incongruous grinning and grimacing = common

• Best described as “silly or fatuous”

CATATONIC TYPE

• Marked disturbance in motor function

• Ayaw mag move

• Stupor

• Negativism

• Rigidity

• Excitement

• Posturing

• Rapid alteration between extremes of excitement and stupor

• Associated features:

o Stereotype mannerism, waxy flexibility

• Mutism = common

• Needs supervision

• Medical care: malnutrition, exhaustion, hyperpyrexia (continuous contraction of muscle due to prolonged position), self-inflicted injury

RESIDUAL TYPE

• Continuing evidence of the schizophrenic disturbance in the absence of a complete set of active sx

• Emotional blunting

• Social withdrawal

• Eccentric behavior – odd behavior

• Illogical thinking

• Mild loosening of associations

SCHIZOTYPAL

• Schizotypal personality disorder is an ingrained pattern of thinking and behavior marked by unusual beliefs and fears, and difficulty with forming and maintaining relationships.

• People with schizotypal personality disorder are uncomfortable with close relationships and may exhibit eccentric behavior.

• Schizotypal avoid social interaction because of deep-seated fear of people.

SCHIZOID

• Schizoid is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment and  apathy.

• The schizoid individuals simply feel no desire to form relationships, because they see no point in sharing their time with others

 BOUFFEE DELIRANTE

• Acute delusional psychosis

• Duration of less than 3 months

• Progress to schizophrenia

LATENT “Borderline schizoid”

• Schizotypal personality d/o

• Occasionally show peculiar behavior or thought but do not consistently manifest psychotic symptoms

• Formerly known as borderline schizophrenia

ONEIROID

• Refers to dreamlike state in which pts. may be deeply perplexed and not fully oriented in time and place.

• Pts. who are deeply engaged in their hallucinatory experiences to the exclusion of the of the real world

PARAPHRENIA

• Paranoid schizophrenia

• Progressive deteriorating course of illness or the presence of well-systemized delusional system

PSEUDONEUROTIC

• Anxiety, phobias, obsessions, compulsions later reveal sx of thought d/o or psychosis

• Borderline personality disorder – grabe kaseloso or attached

SIMPLE DETERIORATIVE DISORDER (SIMPLE)

• Gradual, insidious loss of drive and ambition

• Not overtly psychotic

• Do not experience persistent hallucinations and delusions

• Primary sx: withdrawal from social and work – related situations

POSTPSYCHOTIC DEPRESSIVE DISORDER OF SCHIZOPHRENIA

• Resembles residual schizophrenia

• Adverse effects of antipsychotic medicine

• Depression arising from schizo illness

• Depressive state

• Suicide = high

EARLY ONSET SCHIZOPHRENIA

• Childhood

• MR and autistic d/o

• Onset: insidious

• Course: chronic

• Prognosis: unfavorable (many comorbidities)

LATE ONSET SCHIZOPHRENIA

• Onset after the age of 45

• Common in women

• Paranoid symptoms

• Prognosis: favorable

• Antipsychotic medications

Premorbid sign and symptoms - Clinical Features

• Schizoid or schizotypal personality

• Pre Schizophrenic adolescents

• No friends, no team, avoid team sports

• Sudden onset of OC

Signs: - Clinical Features

• Headache, muscle & back pain, weakness, digestive problems

• Initial Dx: malingering, chronic fatigue syndrome, somatization d/o

• No longer functioning well in occupational, social and personal activities

• Interest in abstract ideas, philosophy, religious questions

• Peculiar behavior, abnormal affect, unusual speech, bizarre ideas, strange perceptual ideas.

Treatment

• Antipsychotic drugs

• Psychosocial interventions

• Hospitalization

Antipsychotic drugs

• Dopamine receptor antagonists

• Haloperidol

• Serotonin-dopamine antagonist

Psychosocial interventions

• Social skills training

• Family – oriented therapies

• Assertive community therapy

• Vocational therapy

Hospitalization

PSYCHOTIC SYNDROMES DO NOT MEET THE DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA

• I - SCHIZOPHRENIFORM DISORDER

• II – SCHIZOAFFECTIVE DISORDER

• III - DELUSIONAL DISORDER

I - SCHIZOPHRENIFORM DISORDER

• Identical to those of schizophrenia except that the symptoms have been present for at least 1 month but less than 6 months

• Progression to schizophrenia – 60 – 80 %

II – SCHIZOAFFECTIVE DISORDER

• Characterized by the presence of a complete syndrome or symptoms for both schizophrenia and a mood disorder

• Depressive type of schizoaffective d/o - More common in older people than in younger people

• Bipolar type - More common in young adults than in older adults

• Lower in men than in women

• Married women

• Age onset of women is later than for men

• Men – exhibit antisocial behavior, flat or inappropriate affect

DIAGNOSIS AND CLINICAL FEATURES DSM – IV – TR CRITERIA (II – SCHIZOAFFECTIVE DISORDER)

• An uninterrupted period of illness during which, at some time, there is either a major depressive episode, a manic episode, or a mixed episode concurrent with symptoms that meet criterion for schizophrenia

• During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms (mood)

• Symptoms that meet criteria for mood episode are present for a substantial portion of the total duration of the active and residual periods of illness (mood)

• The disturbance is not due to physiological effects of a substance (e.g. Drug abuse or  medication) or general medical condition

SPECIFIC TYPE (II – SCHIZOAFFECTIVE DISORDER)

• Bipolar Type

• Depressive Type

Bipolar Type

• if the disturbance includes a manic or mixed episode

Depressive Type

• if the disturbance only includes major depressive episodes

III - DELUSIONAL DISORDER

• Is a chronic disorder, but is characterized by the presence of delusions as the predominant symptoms

DSM-IV-TR (III - DELUSIONAL DISORDER)

• person exhibits non bizarre delusions of at least 1 mo’s duration that cannot be attributed to other psychiatric disorders

• Formerly called paranoia or paranoid disorder

• Can be grandiose, erotic, jealous, somatic and mixed

EPIDEMIOLOGY (III - DELUSIONAL DISORDER)

• Rarer than schizophrenia

• mean age of onset: 40 years

• Range: 18 – 90 y.o

• Common in female

• Married and unemployed

TYPES OF DELUSIONAL DISORDER

1. PERSECUTORY TYPE

2. JEALOUS TYPE

3. EROTOMANIC TYPE

4. SOMATIC TYPE

5. GRANDIOSE TYPE

6. MIXED TYPE

7. UNSPECIFIC TYPE

PERSECUTORY TYPE

• Classic symptom

• Most common

• Feeling nila papatayin sila

JEALOUS TYPE

• Jealousy

  • Conjugal Paranoia

  • Othello Syndrome

• Marked Jealousy

Jealousy

• powerful emotion

• Be potentially dangerous

• Associated w/ violence, suicide and homicide

• Motive for murder

• Verbal and physical abuse – more frequently

Conjugal paranoia

• Leads an individual to experience feelings of extreme jealousy over perceived infidelity; the person typically has no bases for their suspicion

• Delusional disorder w/ delusions of infidelity

• Limited that a spouse has been unfaithful

Othello syndrome

• It is characterized by recurrent accusations of infidelity, searches for evidence, repeated interrogation of the partner, tests of their partner’s fidelity, and sometimes stalking. The syndrome may appear by itself or in the course of paranoid schizophrenia, alcoholism, or cocaine addiction

• Describe morbid jealousy that can arise from multiple concerns

• Men

• May appear suddenly and serve to explain a host of past and present involving spouse’s behavior

• Difficult to treat

Marked Jealousy

• Pathological or morbid jealousy

• A symptom of many disorders including schizophrenia, epilepsy, mood disorders, drug abuse and alcoholism

EROTOMANIC TYPE

• Have delusions of secret lovers

• Woman – common

• Men – susceptible

• Pt believes that a suitor, usually more socially prominent than herself, is in love with her

• Delusion becomes the central focus

• Onset: sudden

• AKA as Psychose personale

• Referred to as de Clerambault’s syndrome

•  Known to occur in schizophrenia, mood d/o and other organic disorders

CHARACTERISTICS OF EROTOMANIC TYPE

• unattractive women in low-level jobs

• Withdrawn

• Lonely lives

• Single

• Few sexual contacts

• Select secret lovers who differ substantially different from them

• Course: chronic, recurrent or brief

• Exhibit paradoxical conduct

  • The delusional phenomenon of interpreting all denials of love, no matter how clear, as secret affirmations of love

• Intervention: separation from the love object

• Men – more aggressive, violent in their pursuit of love

• Stalkers

  • Continually follow their perceived lovers, frequently have delusions

SOMATIC TYPE

• Iba ang pag perceive sa body

• Monosymptomatic hypochondrial psychosis

• Reality impairment

• Frequency: low

• underdiagnosed

• Poor prognosis

• men=women

• Younger pt: hx of substance abuse

• Shame, depression, avoidant behavior

• Suicide - common

• Fixed, Unarguable, Intense

• Pt is totally convinced of the physical nature of disorder

• Often admit that their fear of illness is largely groundless

MAIN TYPES OF SOMATIC TYPE

1. Delusion of infestation (including parasitosis)

2. Delusions of dysmorphophobia (body dysmorphic disorder BDD)

3. Delusion of foul body odors or halitosis

Delusion of infestation (including parasitosis)

• earlier onset (mean: 25 years)

• male

• single

• absence of past psychiatric tx

• feeling may nakatira sa loob ng katawan

Delusions of dysmorphophobia (body dysmorphic disorder BDD)

• is a mental disorder characterized by the obsessive idea that some aspect of one's own body part or appearance is severely flawed and therefore warrants exceptional measures to hide or fix it.

Delusion of foul body odors or halitosis

• olfactory reference syndrome

GRANDIOSE TYPE

• Megalomania – is a personality disorder characterized by a long-term pattern of exaggerated feelings of self-importance, an excessive craving for admiration, and struggles with empathy

• Ako pinakahawd sa tanan

MIXED TYPE

• With 2 or more delusional themes

• Reserved for cases in which no single delusional type predominates

UNSPECIFIC TYPE

• Cannot be subtype w/ previous categories

• Delusions of misidentifications

• Maybe associated w/ schizophrenia, dementia, epilepsy

• Women

• Associated paranoid features

• Feelings of depersonalization or derealization

• Brief, recurrent, persistent

Examples of Unspecific Type

• Capgras syndrome

• Cotard syndrome

Capgras syndrome

• Illusion’s of double

• “imposter syndrome” or “Capgras delusion” (doppelganger)

  • people who experience this syndrome will have an irrational belief that someone they know or recognize has been replaced by an imposter

Cotard syndrome

• Pt complain of having lost not only possession, status, strength but also heart, blood and intestines

• World beyond them is reduced in nothingness

• Rare

• Precursor to a schizophrenic or depressive episode

• Tx: antipsychotic drug

IV - BRIEF PSYCHOTIC DISORDER

• Characterized primarily by the brief duration ( at least 1 day but less than 1 month ) of schizophrenic symptoms