integ: abspych (schizophrenia and other psychotic disorders)

Schizophrenia

• characterized by a broad spectrum of cognitive and emotional dysfunctions including delusions and hallucinations, disorganized speech and behavior, and inappropriate emotions

• Can disrupt a person’s perception, thought, speech, and movement

1 in 7 patients

Full recovery from schizophrenia has a low base rate of how many

John Haslam

• Wrote Observations on Madness and Melancholy

• Defined schizophrenia as “a form of insanity”

• “Sensibility appears to be considerably blunted: they do not bear the same affection towards their parents and relations”

• “They become unfeeling to kindness, and careless of reproof”

Benedict Morel

• Described schizophrenia as démence (loss of mind) and précoce (early,premature)

• Onset of the disorder was believed to be during adolescence

• Mainly focused on early onset and poor outcomes

Emil Kraeplin

• Built on Haslam’s writings and provided the most enduring description and categorization of schizophrenia

• Combined several symptoms of insanity that had usually been viewed as reflecting separate and distinct disorders

Catatonia

• alternating immobility and excited agitation

• severe reduction (withdrawn) or increase (excited) in activity, immobility, mutism, or rigid postures

Hebephrenia

• silly and immature emotionality

• Giggle while talking about something serious

• Speak in a confusing, fragmented way

• Wear mismatched clothes and act in a socially inappropriate manner

Paranoia

delusions of grandeur or persecution

dementia praecox

catatonia, hebephrenia, and paranoia were included under

Eugen Bleuler

• Coined the term schizophrenia

• Wrote Dementia Praecox or the Group of Schizophrenias which emphasized the complexity of the disorder

• Highlighted what he believed to be the universal underlying problem of schizophrenia

split

skhizein

mind

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associative splitting

Eugen Bleuler believed that victims exhibited an what of the basic functions of personality; breaking of associative threads

Hallucinations

involuntary vivid and clear perception-like experiences that occur without an external stimulus and in the context of clear sensorium

Auditory Hallucinations

• involves hearing things that don’t exist

• 2nd most common form of hallucination

Visual Hallucinations

• involve distortions of what one sees or visions of things that aren't there 

• Most common form of hallucination

Tactile Hallucinations

• involve physical sensations on or within the body

• Least common form of hallucination

Olfactory Hallucinations

• involve smelling something that is not there

• Referred to as phantosmia

Gustatory Hallucinations

• involve false taste perceptions

• Fairly prevalent in people with epilepsy and less frequently in schizophrenia

Hypnopompic Hallucinations

• occur while waking up

• Indicator of narcolepsy

Hypnagogic Hallucinations

• occur while falling asleep

• Short, usually auditory

• Most common

Delusions

fixed beliefs not amenable to change in light of conflicting evidence

Delirium

• causes confused thinking and a lack of awareness of surroundings

• An elderly patient suddenly becomes confused at night, sees things that aren’t there, and cannot recognize family members, but seems clearer during the day.

Delusions of Grandeur

• belief that you are superior to other people

• Ex. the chosen one, special destiny

Delusions of Reference

• thinking insignificant events relate directly to you

• Ex. receiving special messages from the TV

Thought Broadcasting

belief that others know your thoughts

Thought Insertion

belief that ideas are implanted on your mind

Thought Withdrawal

belief that thoughts are being removed / stolen from your mind

Persecutory Delusions

• belief that someone or something is "out to get you"

• Most common type of delusion in schizophrenia

• Considered as an extreme form of paranoia

Fregoli’s Syndrome

 belief that a stranger is a familiar person who changes their appearance or is in disguise

Capgras’ Syndrome

belief that familiar people have been replaced by imposters

Jealous Delusions

belief that that your partner is unfaithful

Othello’s Syndrome

• pathological and morbid jealousy

• A person becomes convinced their partner is cheating because they came home late once, and then starts monitoring their activities, accusing them constantly, and refusing to accept any reassurance.

Somatic Delusions

belief that something is wrong with your body

Erotomanic Delusions

belief that someone, typically higher in status, is in love with you

de Clerambault’s Syndrome

erotomanic delusions is also called:

Nihilistic Delusions

• belief that something or someone no longer exists

• Often occur with depression

Cotard’s Syndrome

belief that the body is dead or decaying

Positive Symptoms (Type 1)

additional behaviors not generally seen in people without the condition

Bizarre Behavior

• problems in performing directed daily activities; catatonia

• Wearing multiple layers of clothing in hot weather

• Dancing or gesturing oddly without reason

• Talking to imaginary people

• Engaging in ritualistic or repetitive acts with no clear purpose

Ambivalence

having conflicting reactions, beliefs, or feelings

Abnormal Thought Form

distortions / disturbance in thought processes

Negative Symptoms (Type 2)

indicate the absence or insufficiency of normal behavior

Alogia

• lack of logic / poverty of speech / relative absence of speech

• Question: “How was your day?”
  Response: “Fine.” (no elaboration, even when encouraged)

Affective Flattening

lack of range in emotional reactions

Flat/Blunted Affect

lack of emotion where you normally expect them to; flat and toneless

Anhedonia

• lack of pleasure

• A person who used to love music or spending time with friends no longer feels any enjoyment and prefers to stay alone.

Attention Impairment

lack of concentration

Avolition

lack of motivation

Apathy

lack of reaction to stimuli

Asocial Behavior

lack of interpersonal relationships

Anergia

lack of energy

Disorganized Thinking (Speech)

• distortion in thinking observed through speech

• Also called formal thought disorder

• Question: “How are you feeling today?”
  Response (disorganized):
  “I’m feeling blue, the sky is true, you flew—time is glue, and shoes are news.”

Derailment / Loose Associations

switching from one topic to another

Tangentiality

answering questions that are unrelated or obliquely related

Incoherence

• word salad, resembles receptive aphasia in its linguistic disorganization

• Even though the words are real, the sentence has no clear meaning

• ex: “Blue sleep runs quickly table happiness jump green.”

Echolalia

• repetition of words spoken by another person

• ex: Person A: “Do you want water?”
  Person B: “Want water… want water…”

Palilalia

• repetition of own words / syllables

• ex: “I’m going home… home… home… home…”

Verbigeration

• senseless repetition of words, phrases, or sentences, often without communicative purpose

• ex: “Time goes, time goes, time goes, time goes…” | “Blue sky, blue sky, blue sky…”

Coprolalia

• use of obscene / inappropriate words

• swearing or sexual phrases

• ex: A person suddenly blurts out a curse word in a quiet room or formal setting without any clear reason

Clang Association

• use of rhyming words rather than their meaning

• rhyming, alliteration, or puns

• ex: The train brain rain goes down the lane in Spain

Grossly Disorganized or Abnormal Motor Behavior

• movement that ranges from childlike "silliness" to unpredictable agitation

• Also called catatonic behavior

• disturbances in a person’s physical actions

• ex: Wearing heavy clothes in hot weather, Laughing or crying without clear reason, Repeating odd gestures or postures, Sudden agitation or restlessness, Standing still for long periods without moving

Catatonic Behavior

marked decrease in reactivity to the environment

Negativism

resistance to instructions

Catatonic Excitement

purposeless and excessive motor activity without obvious cause

Catalepsy

• maintains a fixed, often uncomfortable posture for a prolonged period, with decreased response to external stimuli.

• Person appears “frozen” or statue-like

• you can move their body, and they’ll hold that position

• ex: A person’s arm is lifted by someone else, and they keep it raised for several minutes without resistance or adjustment.

stupor

• lack of movement for a long period of time

• Doesn’t move

• Doesn’t speak (mutism)

• Minimal or no response even when stimulated

• person is almost completely unresponsive

• ex: A person may remain frozen in one position, not speaking or reacting, even when others try to engage them

Stereotypy

• repetition of purposeless movement

• Hand flapping

• Rocking back and forth

• Repeating the same sounds or words (in some cases)

• Head banging or body swaying

Inappropriate Affect

exhibit bizarre behaviors such as hoarding objects or acting in  unusual ways in public

Historic Schizophrenia Subtypes

previously used in the DSM-IV-TR but dropped in the DSM-5

Schizophrenia

key feature: 2+ symptoms (1+ core), disorganized / negative symptoms

duration: ≥6 months (1+ active)

Schizophreniform

key feature: Same as schizophrenia

duration: 1–6 months

Brief Psychotic Disorder

key feature: 1+ psychotic symptom (core)

duration: 1 day to <1 month

Schizoaffective

• key feature: Mood episode + psychosis alone ≥2 weeks

• duration: variable

• A person hears voices even when they are not depressed or manic, but also has long periods of severe depression

Delusional Disorder

key feature: 1+ delusion, no other psychosis

duration: ≥1 month

Delusional Disorder

• at least 1 month of what but no other prominent psychotic symptoms

• imagined events could be happening but aren’t

• Relatively rare type of disorder

Folie à Deux

condition in which an individual develops delusions simply as a result of a close relationship with a delusional individual

Grandiose

• believing in one’s inflated worth, power, knowledge, identity, or special relationship to a deity or famous person

Persecutory

believing oneself (or someone close) is being malevolently treated in some way

delusional disorder

• Onset is relatively late (35-55)

• Tends to fare better in life than people with schizophrenia but not as well as those with some other psychotic disorders, such as schizoaffective disorder

Substance-Induced Psychotic Disorder

commonly affects those who abuse amphetamines, alcohol, and cocaine

Psychotic Disorder Associated with Another Medical Condition

commonly affects those with brain tumors, Huntington’s disease, and Alzheimer’s disease

delusional disorder

• Presence of delusions ( at least 1 month or more)

• Has never fully met Criteria A of Schizophrenia (at least 2 or more; at least 1 from first 3)

  • Delusions

  • Hallucinations

  • Disorganized speech

  • Grossly disorganized or catatonic behavior

  • Negative symptoms

  • Functioning is not markedly impaired

• Duration: 1 month or more

Criterion A: Core Symptoms

2 or more of the following (for at least 1 month), and at least one must be 1–3:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

Criterion B: Functional Impairment

Significant decline in:

• Work

• Relationships

• Self-care

Criterion C: Duration

• Continuous signs of disturbance for at least 6 months

• Must include:

  • ≥1 month of active symptoms (Criterion A)

  • Remaining time may be prodromal or residual symptoms

Criterion D: Mood Disorder Exclusion

• OR if mood episodes occur, they are present for only a minority of the total duration

• not better explained by:

  • Schizoaffective Disorder

  • Bipolar Disorder

  • Major Depressive Disorder with psychotic features

Criterion E: Substance/Medical Exclusion

Not due to:

• Drugs (e.g., substance use)

• Another medical condition

Criterion F: Developmental Disorder Rule

• diagnosed only if:

• Prominent delusions or hallucinations are present for at least 1 month

Mixed Type

Applies when no one delusional theme predominates

Unspecified Type

• Applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types 

• Ex. referential delusions without a prominent persecutory or grandiose component

Brief Psychotic Disorder

• presence of one or more positive symptoms such as delusions, hallucinations, or disorganized speech or behavior lasting 1 month or less; may or may not be accompanied by grossly disorganized or catatonic behavior

• Many eventually regain their ability to function in less than a month

Brief Psychotic Disorder

• Often precipitated by extremely stressful situations

• They typically experience emotional turmoil or overwhelming confusion and have rapid shifts from one intense affect to another

Attenuated Psychosis Syndrome

•  symptoms that are psychotic in nature but below the threshold for consideration as counting towards the diagnosis of a psychotic disorder

• High risk for developing schizophrenia

• Unusual thoughts or beliefs (but still somewhat aware they might not be true)

• Mild hallucinations (e.g., hearing faint voices occasionally)

• Suspiciousness or paranoia

attenuated psychosis syndrome

ex: Maria, 17 years old:

• She sometimes feels like her classmates are talking about her behind her back, even when there’s no clear evidence.

• She has brief moments of hearing her name whispered, but when she checks, no one is there.

• She admits: “I know it might just be in my head, but it still scares me.”

• Her school performance has dropped because she’s anxious and distracted.

Prodromal

early stage

Sudden Onset

change from a nonpsychotic state to a clearly psychotic state within 2 weeks, usually without a prodrome

brief psychotic disorder

• Presence of psychotic symptoms (at least 1 or more)

  • Delusions

  • Hallucinations

  • Disorganized speech

  • Grossly disorganized or catatonic behavior

• Functioning is not markedly impaired

Duration: 1 day to a month

With marked stressor(s) (brief reactive psychosis)

If symptoms occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual’s culture

Without marked stressor(s)

If symptoms do not occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual’s culture.