Chapter 15 Psychotic disorders

 Definition : characterized by a significant impairment in reality testing 1. Delusions or hallucination (with/without insight into there pathological nature) 2. Behavior so disorganized that it is reasonable to infer that reality testing in disturebed.

Differential diagnosis of psychosis 1. Primary psychotic disorder: schizophrenia, schizophreniform, brief psychotic, schizoaffective, share psychotic, delusional disorder 2. Mood disorder : depression whit psychotic features, bipoler, disorder with psychotic feature 3. Personal disorder : schizotypal, schizoid borderline paranoid obsessive-compulsive

4. General medical condition : tumour, head trauma, dementia, deliriam, metabolic, infection, stroke,temporal lobe epilepsy 5. Substance : induced psychosis inloxication or withdrawal, prescribed medication,toxins

Both patients and their families often suffer from poor care and social ostracism because of widespread ignorance about the disorder. Classification or subtypes of Schizophrenia ( based on prominent clinical features) 1.Simple schizophrenia 2.Paranoid schizophrenia 3.Catatonic schizophrenia 4.Hebephrenic/disorganized schizophrenia 5.Undifferentiated schizophrenia 6.Residual schizophrenia 7.Deficit syndrome

Diagnostic criteria for schizophrenia according to DSM-IV A.Characteristic symptoms (active phase): ≥2 of the following each present for a significant portion of time during a 1- month period (or less if successfully treated) #delusions # hallucinations # disorganized speech (e.g. frequent derailment or incoherence) # grossly disorganized or catatonic behaviour # negative symptoms, e.g. affective flattening, alogia (inability to speak), or avolition (inability to initiate and persist in goal directed activities) Note: only one symptom of A is required if delusions are bizarre or hallucinations consist of a voice keeping a running commentary on the persons behaviour or thoughts or 2 or more voices conversing with each other.

B. Social or occupational dysfunctions: ≥1 major areas of functioning (work, interpersonal relationship, self care) markedly below the level achieved prior to the onset of symptoms. C. Continuous signs of disturbance for ≥6 months including ≥1 month of active phase symptoms; may include prodromal or residual phases D. Schizoaffective and mood disorders excluded E. The disturbance is not due to the direct physiological effects of a substance or a GMC F. If history of pervasive developmental disorder, additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 month.

Usually features present in schizophrenia 1.Hallucination 2.Thought echo 3. Running commentary 4. Delusion of control 5.Delusional perception 6.Delusion of thought withdrawal and insertion 7. delusion of thought broadcast 8.Tectile and gustatory hallucination 9. Speech not comprehensive 10.Lack of initiation Sometimes lack of speech 11. isolation 12. apathy 13.Potentiality debilating 14.oss of potentiality 15. patient at the increased risk of himself and family members 16. social isolation 17. unable to hold up job 18.Childlike behaviour

Subtypes 1.Paranoid # preocupation with delusions (typically persecutory or grandiose) or frequent auditory hallucinations # relative preservation of cognitive functioning and affect; onset tends to be later in life; believed to have the best prognosis 2. Catatonic # at least two of: motor immobility (catalepsy or slupor); excessive motor activity (purposeless); extreme negativism (resistance to instructions/attempts to be moved) or mutism; peculiar voluntary movement (posturing, stercotyped movements, prominent mannerisms) echolalia or echopraxia (copying anothers speech or movement) 3.Disorganized # disorganized speech and behaviour; flat or inappropiate affect

# poor premorbid personality, early and insidious onset, and continuous course without significant remissions 4.undifferentiated meets criteria for schizophrenia, but does not fall into the 3 previous subtypes 5. Residual # no longer have prominent delusions, hallucinations, disorganised speech, grossly disorganized or catatonic behaviour # continuing evidence of residual illness such as negative symptoms or attenuated symptoms of criteria A

# neuroanatomy – decreased frontal lobe function, asymmetric temporal/limbic function, decreased basal ganglia function; subtle changes in thalamus, cortex, corpus callosum, and ventricles; cytoarchitectural abnormalities # neuroendocrinology – abnormak growth hormone, prolactin, cortisol and adrenocorticotropic hormone. #neuropsychology – global deffects seen in attention, language, and memory suggest lack of connectivity of neural networks. # environmental – indirect evidence of cannabis use, geographical variance, winter season of birth, obstetrical complications, and prenatal viral exposure.

Epidemiology 1.prevalence: 0.5%; M:F= 1:1 2.Mean age of onset: females ~ 27 males~ 21 Etiology 1. multifactorial: disorder is a result of interaction between both biological and environmental factors # genetic – 40% concordance in monozygotic twins; 46% if both parents have schizophrenia; 10% of dizygote twins, siblings, children affected. # neurochemistry – dopamine hypothesis theory: excess activity in the mesolimbic dopamine pathway may mediate the positive symptoms of psychosis while decreased dopamine in the prefrontal cortex may mediate negative and cognitive symptoms; GABA, glutamate, and Ach dysfunction are also thought to be involved.

# neuroanatomy – decreased frontal lobe function, asymmetric temporal/limbic function, decreased basal ganglia function; subtle changes in thalamus, cortex, corpus callosum, and ventricles; cytoarchitectural abnormalities # neuroendocrinology – abnormak growth hormone, prolactin, cortisol and adrenocorticotropic hormone. #neuropsychology – global deffects seen in attention, language, and memory suggest lack of connectivity of neural networks. # environmental – indirect evidence of cannabis use, geographical variance, winter season of birth, obstetrical complications, and prenatal viral exposure.

Pathophysiology Neurodegenarative theory # natural history may be rapid or gradual decline in function and ability to communicate # glutamate system may mediate progressive degenaration by excitotoxic mechanism which leads to production of free radicals Neurodevepmental theory : abnormal development of the brain from prenatal life # neurons fail to migrate correctly, make inappropriate connections and break down in later life # inappropriate apoptosis during neurodevelopment resulting in faulty connections between neurons

Schneiders first rank symptoms 1.Audible thought 2.Voices arguing or discussing or both 3.Voices commenting 4.Somatic passivity experiences 5.Thought withdrawal and other experiences of influenced thought 6.Thought broadcasting 7.Delusional perceptions 8.All other experiences involve volition, made affects and made impulses

Management of schizophrenia Prognosis of schizophrenia depends on type of schizophrenia. Type I – good prognosis Type II –bad prognosis

factor Type1type II Tipe iiacute insiduious Tipe normalpoor Tipe iiirritable blunted or flat Tipe iidelusions, hallucinations poverty of speech and thought content Tipe ii normalcognitive impairement apathy, anhedonia CT scannormalcerebral atrophy Prognosisgoodpoor

Biological # acute treatment and maintenance with antipsychotics +/- anticonvulsants +/- anxiolytics Psychosocial # psychotherapy: supportive, CBT- patient/ family education, repair family tights, provide coping strategies for symptoms, improve cognitive skillness # assertive community treatment : mumbai mental health team that provide individual treatment in the community and help patients with basic living skills, social support, job placement and community resources # social skill training, employment programme, disability benefit # housing

Course and prognosis Good  Sudden onset  Short episode  No previous psychiatric history  Older age onset  Prominent affective symptoms  Married  Good psychosexual adjustment  Good work record  good social relationship  Good complains Bad  insidious onset  long episode  previous  psychiatric history present  negative symptoms  divorced  poor psychosexual  adjustment  abnormal previous  personality  poor work record  isolation  bad complains

1.The majority of individuals display some type of prodromal phase 2.Course is variable; some individuals have excerbations and remissions and others remain chronically ill., accurate prediction of the long term outcome is not possible. 3.Early in the illness, negative symptoms, positive symptoms appears and typically diminish with treatment; negative symptoms may become more prominent and more disabling. 4.Over time, 1/3 improve, 1/3 remain the same, 1/3 worsen.

The End