Week 3: Schizophrenia Spectrum and Other Psychotic Disorders

What is the history of schizophrenia?

Very broad and encompassing. Research has come largely from Europe. Everything from demon possession and morality-based to resulting from poor diet. Could schizophrenia be caused by a virus?

What did Dr. John Haslam say?

“The 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. … I have painfully witnessed this hopeless and degrading change, which in short time has transformed the most promising and vigorous intellect into a slavering and bloated idiot” (Haslam, 1809/1976, p. 65-67). Autistic fantasy, do not respond to love and criticism

What happened 50 years after Haslam?

Belgian psychiatrist Benedict Augustin Morel (1860) standardized and formally described symptoms of schizophrenia using the French terms demence (loss of mind) and precoce (early, premature). German psychiatrist Emil Kraepelin (1896) was the first to use the term schizophrenia. - Several types of mental abnormalities previously viewed as separate and distinct disorders that shared similar underlying features. Distinguished three subtypes of that were included under the Latin term dementia praecox (Catatonia – alternating immobility and excited agitation. Hebephrenia – silly and immature emotionality. Paranoia – delusions of grandeur or persecution)

What is dementia praecox?

Three subtypes of schizophrenia: (Catatonia – alternating immobility and excited agitation. Hebephrenia – silly and immature emotionality. Paranoia – delusions of grandeur or persecution)

What is Catatonia to Kraepelin?

alternating immobility and excited agitation.

What is Hebephrenia to Kraepelin?

silly and immature emotionality

What is Paranoia Kraepelin?

delusions of grandeur or persecution (people are out to get me)

Kraepelin put forth the central features of?

Early onset – adolescence (18-25). Develops into a “moral weakness” marked by (Hallucinations, Delusions, Negativism). The diagnosis results from changes in the brain. Evolved into a long-term chronic course due to brain deterioration - particularly if diagnosed early in life and no treatment is provided

What are hallucinations?

Refers to the five senses

What are delusions?

Refers to the thoughts/beliefs

What is negativism?

Refers to little or no response to external stimuli. Tendency to resist external commands. opposition or no response to instructions or external stimuli

Who coined the term “schizophrenia?”

Eugene Bleuler

Who is Eugene Bleuler?

A Swiss psychiatrist in 1911. Differed from Kraepelin’s conceptualizations and talked of “different” schizophrenias. Disturbances of: (Feelings (affect and mood), Thinking (process and content), Relationships to the outside world (narcissistic tendency toward inwardness)). “Associated splitting” of the basic functions of personality. Most prominent features of schizophrenia were: (The tearing apart of the individual’s psychic functions - Especially evident in inappropriate behavior. Losing associations between ideas, and disorganization of thought, affect and actions). Skhizein – “split” and phren – “mind.”- Meaning “Shattered personality” NOT “Dissociative Identity Disorder.” The new word preplaced terms such as “madness,” “lunacy,” and “dementia praecox.”

What are Blueler’s 4 A’s?

Associations, affect, autism, ambivalence

What is association in Blueler’s 4 A’s?

The logical thought processes are altered so that speech loses its coherence (associations are loosened). The person may create his/her/their own words - Neologism

What is affect in Blueler’s 4 A’s?

Observable manifestations of a person’s mood or emotion. Emotional indifference – reduction in pleasurable experiences.

What is autism in Blueler’s 4 A’s?

Significant impairment in social interactions, communication, and restricted patterns of behavior, interest, or activity.

What is ambivalence in Blueler’s 4 A’s?

Positive and negative values that exist simultaneously; these include uncertainty about taking a particular direction or vacillating between two different perspectives and/or courses of action. - (kitchen or bathroom first? - can’t decide)

What did Kurt Schneider in the 1930s conceptualize?

Positive and Negative Symptoms

What are positive symptoms to Schneider?

Disorganized Thinking. Disorganized behavior - Somatic passivity experiences of inertia - person can’t move. Catatonic behavior - Muscular rigidity and immobility and Stupor and negativism or state of excitement. Delusions - Thought withdrawal (believing thoughts have been removed from your head and Thought broadcasting (believing passages from books, TV, are specifically directed at oneself). Hallucinations. Other - Unusual motor behavior, Depersonalization, Derealization, Somatic preoccupations (preoccupied with bodily parts and sensations)

What are negative symptoms to Schneider?

Loss of feeling or inability to experience pleasure (anhedonia) - (Lack of interest in social or recreational activities). Poverty of speech (alogia) - (Amount of speech is greatly reduced and tends to be vague or repetitious. Flat presentation (affective flattening)) - (Depressive and euphoric mood changes and Unchanging facial expressions, poor or no eye contact, reduced body language, and decreased spontaneous movements). Withdrawal, loss of motivation, and ambivalence (avolition) - (Feelings of emotional impoverishment or seeming lack of interest in what were usual activities, Inattentive to personal grooming, hygiene, and Difficulty persisting at work, school, or household chores).

Is schizophrenia actually one or several disorders?

The DSM-5 characterizes schizophrenia as a heterogeneous clinical syndrome involving features characterized by abnormalities in one or more of the following five domains: (Delusions, Hallucinations, Disorganized thinking (speech), Grossly disorganized or abnormal motor behavior (including catatonia), and Negative symptoms.

What are the Current thoughts on schizophrenia?

Characterized by a broad range of behaviors marked by a: (Loss of the person’s sense of self, Significant impairment in reality testing, Disturbances in feeling, thinking, and behavior). The person is often unaware of their symptoms or even may contest having any symptoms

What is the Neurodevelopmental hypothesis?

There is a disease process that affects brain areas very early in life and gradually continues to the point where full-blown symptoms emerge. We do see early problems and brain changes as the child develops. (Decline in intelligence, Trouble paying attention, More withdrawn, neurotic, depressive, solitary, aggressive, and disruptive behaviors, Home environment may cause increased stress that worsens symptoms. Giving someone a predictable routine can help them rejoin life). We have no evidence that a single gene causes any problem - (But, we do see evidence in monozygotic versus dizygotic twin studies. The more genes shared with a person who has the disorder, the more likely the offspring will have it).

What is The role of dopamine?

Somehow the system is too active. Excessiveness of this may mediate the symptoms of auditory hallucinations or delusions, while deficientness in the cortical regions may mediate the negative symptoms. So, schizophrenia is partially attributable to excessive activity of this.

Key features of schizophrenia?

Negative symptoms and Positive symptoms

What are the current negative symptoms?

Blunted or flat affect, No eye contact, Prosody – intonation of speech, Avolition – no goal-directed behavior, Inappropriate – mood-incongruent behavior, Anhedonia, Asociality). Disorganized or abnormal motor behavior - (Catatonia, Negativism, Stupor, Mutism).

What are the current positive symptoms?

Delusions - (Grandiose, Persecutory, Referential, Erotomanic, Nihilistic, Somatic, Thought Withdrawal/Insertion, Delusions of control). Hallucinations - Auditory/Visual/Tactile/Olfactory/Gustatory. Disorganized thinking - (Echolalia, Tangentiality, Derailment, Loosened associations, Neologism, Perseveration, Clanging)

Grandiose?

Person believes they’re some remarkable person in history - Jesus, Cleopatra, Joan of Arc or Virgin Mary

Persecutory?

Other people are out to get them

Referential?

A benign event is thought to have a very personal meaning. Person did x to try to harm them. Neighbor’s dog was bought deliberately to annoy them, barking is used to send messages to Chinese/Russions/People trying to harm them

Erotomanic?

Belief that someone is in love with you when it is likely the person barely knows you

Nihilistic?

Everything should be broken down and started again

Somatic?

Preoccupation with body parts/sensations

Thought Withdrawal/Insertion?

Taking away or putting thoughts in

Delusions of control?

Other people have control of your thoughts, control of your body, control over you in some way

What are the Phases of the schizophrenic cycle?

Prodromal, active, residual

What is prodromal?

Level of functioning deteriorates. You are coming down with something. Onset usually of the negative symptoms.

What is active?

Symptoms persist for at least 6 months with the individual exhibiting psychotic features.

What is residual?

Symptoms have decreased to the point that the person no longer has enough features for the practitioner to certain the presence of schizophrenia. You drink all the milk in the glass, but there’s residue on the sides of the glass.

Differential Assessment of schizophrenia?

Two diagnostic criteria must be met over much of the time of a period of at least 1 month, with a significant impact on the individual’s social and occupational functioning for at least 6 months. (Delusions, Hallucinations, Disorganized speech). Excludes other disorders specifically schizoaffective and mood disorder. After 1 year, the following specifiers would be considered: (First episode, currently acute episode. First episode, currently in partial remission. First episode, currently in full remission. Multiple episodes, currently in acute episodes. Multiple episodes, currently in partial remission. Multiple episodes, currently in full remission. Continuous: Symptoms remain for the majority of the course of the illness, with subthreshold symptom periods being very brief. Unspecified: Used when there is an underdetermined course).

First episode specifier?

currently acute episode, currently in partial remission, currently in full remission

Continuous specifier?

Symptoms remain for the majority of the course of the illness, with subthreshold symptom periods being very brief.

Unspecified specifier?

Used when there is an underdetermined course.

What can be with a multiple episode specifier?

currently in acute episode, currently in partial remission, currently in full remission

What is The key for diagnostic criteria for schizophrenia?

The presence of at least - (psychotic factors such as delusions, Hallucinations, Disorganized speech). Duration includes continuous signs and symptoms that must persist for at least 6 months - 1 month must include features of psychosis (or the active phase). It is important to know that the person may not be a good historian - a person cannot report signs/sxs.

The Disorders! Ranked from least to most severe.

Delusional Disorder 297.1 (F22), Brief Psychotic Disorder 298.8 (F23), Schizophreniform Disorder 295.40 (F20.81). Schizophrenia 295.90 (F20.9). Schizoaffective Disorder 295.70 (F25.1). Substance/Medication-Induced Psychotic Disorder 291.9-292.9. Psychotic Disorder Due to Another Medical Condition

What is delusional disorder?

Persistent belief about something that is contrary to reality. The thoughts may seem very plausible (i.e. they are not bizarre)!!!!!! The person does not exhibit some of the other features commonly associated with schizophrenia - no hallucinations or negative sxs. The onset is relatively late in life – usually 40s. It is possible that these individuals lead otherwise relatively normal lives and do not feel the need to seek help and do not come to the attention of practitioners. Usually enter treatment when the symptoms become problematic and are ego-dystonic - when they are distressing enough to the person

What is Delusional Disorder, prevalence?

Rare: Lifetime prevalence is estimated at about 0.2%. There appear to be no gender differences except in the jealous type where there are more men. Also, the prevalence may be higher for people with the disorder who are high functioning and perhaps isolative or do not come to the attention of others.

Delusional disorder: Differential assessment?

Delusions must last for at least 1 month!! The delusions are non-bizarre, (but also not valid) which primarily involve situations that could occur in real life: (Being spied on, Followed, Poisoned, Deceived, Conspired against, Loved from a distance). The person’s functioning is not obviously impaired.

Types of Delusional Disorder?

Erotomatic, grandiose, jealous, persecutory, somatic, unspecified

Erotomanic delusions in delusional disorder?

Involves the belief that someone is in love with him.

Grandiose delusions in delusional disorder?

The person has an overinflated sense of worth – a sense of having some great but unrecognized talent, or insight.

Jealous delusions in delusional disorder??

The person believes that his/her spouse/partner is unfaithful.

Persecutory delusions in delusional disorder??

The person believes that he/she is being mistreated

Somatic delusions in delusional disorder??

Involves bodily functions or sensations, and the person believes he/she has a physical defect or medical problem.

Unspecified delusions in delusional disorder?

The dominant delusional belief cannot be clearly determined.

Delusional disorder: Duration specifiers?

Acute, Currently in partial remission, Full remission, Continuous, Unspecified. Remember to rule out substance abuse and major neurocognitive disorder.

What is Brief Psychotic Disorder 298.8 (F23)?

Also known as Brief Reactive Psychosis. We’re not sure what the specific cause is. (Perhaps a genetic link, Poor coping skills, Seems to be triggered by major stress or a traumatic event). 3 forms (With marked stressors: A response to a markedly stressful event such as a trauma, Without marked stressors: There is no obvious stressor With peripartum onset: Usually within 4 weeks after giving birth). Catatonia may also be specified. At least 3 of the 12 characteristic symptoms (Stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, and echopraxia). The outcome is typically good. Make sure to rule out substance abuse, MDD, bipolar, malingering, and factitious disorders.

Stupor?

Unresponsiveness

Catalepsy?

Sudden loss of muscle tone. assuming a posture held against gravity. state of extreme immobility and rigidity, characterized by a lack of responsiveness to external stimuli and a tendency to maintain any position in which the body is placed

Waxy flexibility?

Decreased response to stimuli and a tendency to remain in an immoble posture

Mutism?

Inability to speak

Posturing?

spontaneous and active maintenance of a posture against gravity

Mannerism?

Types of physical actions, reactions, and gestures that are customary and habitual in an individual. odd, circumstantial caricature of normal actions

Stereotypy?

Physical movements that are both aimless and repetitive. repetitive, abnormally frequent, non-goal-directed movements

Agitation?

Excessive motor activity associated with a feeling of inner tension

Grimacing?

Facial expressions that indicate a strong emotion such as displeasure, pain, or anger

Echolalia?

Unsolicited reputation of vocalization made by another person

Echopraxia?

Pathological automatic imitative response, or desire to mimic others behaviors

Brief reactive psychosis: Prevalence?

Not known but people may recover or move out of psychosis spontaneously. Accounts for 9% of cases of first-onset psychosis. Occurs twice as often in women.

Brief reactive psychosis: Differential assessment?

SUDDEN ONSET!!! We typically see the individual’s full return to functioning. Think of it as a time-limited schizophrenia (Resolves within 1 month’s time)!! The individual has at least one major psychotic symptom of either delusions, hallucinations, or disorganized speech. Grossly disorganized or catatonic behavior may also be present. The person may still be very impaired and might need supervision to ensure protection from harm (The loss of a parent. A life-threatening accident. The birth of a child).

What is Schizophreniform Disorder 295.40 (F20.81)?

Very similar to schizophrenia, but not at the same level. The disorder presents, but differentiates from, the symptoms suggestive of schizophrenia AND the symptoms disappear just as quickly as they appear.Time is different than brief reactive psychosis.

Schizophreniform Disorder: prevalence?

Pretty low prevalence rates: Likely due to the quickly made diagnosis of schizophrenia

Schizophreniform Disorder: Differential assessment?

Psychotic features must last less than 6 months and include prodromal, active, and residual phases. It appears as though the person has schizophrenia, but subsequently recovers with no lingering effects. The symptoms and criteria for schizophreniform are identical to those of schizophrenia (The important distinctions are in the duration and intensity). Two-thirds of those with schizophreniform disorder advance toward developing schizophrenia or schizoaffective disorder. Person will need ongoing therapy

What is Schizophrenia 295.90 (F20.9)?

The key is 2 or more of the following symptoms: (Delusions, Hallucinations, Disorganized speech (e.g., frequent derailment or incoherence), Grossly disorganized or catatonic behavior, Negative symptoms (i.e., diminished emotional expression)). Level of functioning in one or more major life areas such as work, interpersonal relations, or self-care is markedly below the level prior to the onset. 6 months. At least 1 month of symptoms in the active phase and may include periods of prodromal or residual symptoms. Remember to use the specifiers.

Schizophrenia: Prevalence?

Lifetime prevalence is approximately 0.3% to 0.7%. Some differences by race/ethnicity, across countries and by geographic regions. Does socioeconomic class play a role? Perhaps people who are of middle income and get into therapy can nip it in the bud and it is actually schizophreniform. Maybe people who cannot afford effective therapy have schizophreniform that does not go away and stays as schizophrenia. Sex ratio seems to be higher for men. The age of onset seems to be later for females (Symptoms also seem to be more affect-laden among females). Lifetime prevalence rates are 0.3 percent to 0.7 percent. Slightly higher in men. Males tend to have symptoms at a younger age than females. Median age at onset is 22 (18-25).

What is Schizoaffective Disorder 295.70 (F25.1)?

The individual shows symptoms of having schizophrenia along with mood disorders! This disorder forms a link between psychosis and mood. The prognosis is better than for an individual with schizophrenia, but worse than for someone with a mood disorder!!!

Schizoaffective disorder: Prevalence?

Appears to be about one-third as common as the diagnosis of schizophrenia. Lifetime prevalence is about 0.3%.

What is Substance/Medication-Induced Psychotic Disorder 291.9-292.9?

Two major symptoms (Delusions and Hallucinations). The individual may or may not have insight. We need to make sure that the psychosis was not present before the use of alcohol or other drugs, or medication that could bring about hallucinations and delusions.

What is Psychotic Disorder Due to Another Medical Condition 293.81-293.82 (F06.2-F06.0)?

Characterized by the presence of hallucinations or delusions. a diagnosis given when psychotic symptoms are caused by a medical illness, such as a brain tumor, stroke, or migraineThe social worker must specify the predominant symptom.

What is Catatonia Associated with Another Mental Disorder 293.89 (F06.1) (Catatonia Specifier)?

We would see 3 or more of the 12 psychomotor features: (Stupor. Catalepsy (assuming a posture held against gravity). Waxy flexibility. Mutism. Negativism (opposition or no response to instructions or external stimuli). Posturing (spontaneous and active maintenance of a posture against gravity). Mannerisms (odd, circumstantial caricature of normal actions).. Stereotypy (repetitive, abnormally frequent, non-goal-directed movements). Agitation. Grimacing. Echolalia. Echopraxia). Note: Indicate the name of the associated mental disorder “Catatonia Associated with Major Depressive Disorder).

What is Catatonic Disorder due to Another Medical Condition 293.89 (F06.1)?

We would see 3 or more of the 12 psychomotor features: (Stupor. Catalepsy (assuming a posture held against gravity). Waxy flexibility. Mutism. Negativism (opposition or no response to instructions or external stimuli). Posturing (spontaneous and active maintenance of a posture against gravity). Mannerisms (odd, circumstantial caricature of normal actions).. Stereotypy (repetitive, abnormally frequent, non-goal-directed movements). Agitation. Grimacing. Echolalia. Echopraxia). Look for the lab findings, H&P to be sure that the disorder is not better explained by a mental disorder. Make sure you’re not seeing Delirium!! Be sure to code the name of the medical condition “Catatonic Disorder due to Hepatic Encephalopathy.”

What is Unspecified Catatonia 293.89 (F06.1)?

We would see symptoms of Catatonia, but we would be unable to determine the cause or have enough time to do a thorough assessment.

What is Other Specified Schizophrenia and Other Psychotic Disorder 298.8 (F28)?

We would see a clinical presentation in which the symptoms are characteristic of a schizophrenia spectrum and other psychotic disorders that cause clinically significant distress in social, occupational, or other important areas of functioning but they do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class. The social worker chooses to communicate the specific reason that the presentation does not meet the full criteria for any specific disorder followed by the specific reason (Persistent Auditory Hallucinations. Delusions with Significant Overlapping Mood Episodes. Attenuated Psychosis Syndrome).

What is Unspecified Schizophrenia and Other Psychotic Disorder 298.9 (F29)?

Symptoms characteristic of a schizophrenia spectrum and other psychotic disorders that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning but do not meet the full criteria for any of the disorders in the schizophrenia spectrum. The social worker may not have sufficient time to do a thorough assessment or retrieve all of the necessary information to make a definitive diagnosis.