1. Schizophrenia

2. Psychosis
A severe mental condition in which there is disorganization of the personality, deterioration in social functioning, and loss of contact with, or distortion of, reality. There may be evidence of hallucinations and delusional thinking. Psychosis can occur with or without the presence of organic impairment.

3. Schizophrenia Spectrum and Other Psychotic Disorders
Schizotypal personality disorder Delusional Disorder Brief Psychotic disorder Schizophreinform Disorder Schizophrenia Schizoaffective disorder Substance / medication – induced psychotic disorder Psychotic disorder due to another medical condition Catatonia

4. Diagnostic Criteria 1. Delusions Bizarre delusions such as:
A. Two or more of the following almost all day most days of the month: at least one of these must be 1, 2, or 3
1. Delusions
Bizarre delusions such as:
Example
A person’s belief that a stranger has removed his or her internal organs and has replaced it with someone else’s organs without leaving any wounds or scars
Thought broadcasting
Thought insertion
Delusion of being controlled
Thought withdrawal
Paranoid delusions

5. Delusion Types
Persecutory delusion: the person believes he or she is being tormented, followed, tricked, spied on, or ridiculed.
Referential delusions: the person believes certain gesture, comments, passage from a book, newspapers, songs or other environmental cues are specially directed towards him or her
Thought broadcasting
The person believes that his thoughts are being broadcasted by TV, Radio, or being read by other people

6. Delusion Types
Thought withdrawal: a person’s belief that his or her thought have been taken away by some outside force (or stolen)
Thought insertion: alien thoughts have been put into his or her mind (thoughts are implanted in their minds from outside source)
Delusion of being controlled: the person’s body or actions are being acted upon or manipulated by some outside force

7. Delusion Types
Erotomanic: With this type of delusion, the individual believes that someone, usually of a higher status, is in love with him or her.
Grandiose: Individuals with grandiose delusions have irrational ideas regarding their own worth, talent, knowledge, or power.
Somatic: Individuals with somatic delusions believe they have some physical defect, disorder, or disease.

8. Delusion Types
Jealousy: The content of jealous delusions centers on the idea that the person’s sexual partner is unfaithful.
Nihilistic: The individual has a false idea that the self, a part of the self, others, or the world is nonexistent (e.g., “The world no longer exists,” “I have no heart.”).
Mixed

9. Diagnostic Criteria
2. Hallucinations: are perception like experiences that occur without an external stimuli.
They are vivid and clear
With full force and impact of normal perceptions, and not under voluntary control
Mostly auditory
Two talking about the patient as a third person,
Voices conversing together
One voice running commentaries on the patient’s thoughts or behaviors

10. Diagnostic Criteria Types of Hallucination
Note: Those hallucination that occur while falling asleep (hypnagogic) or waking up (hypnopompic) are considered within normal. Hallucination may be a normal part of religious experience in certain cultural contexts.
Types of Hallucination
Auditory: are false perceptions of sound or voices
Visual: These are false visual perceptions.
Gustatory: are false perceptions of the sense of touch, often of something on or under the skin.
Tactile: This type of hallucination is a false perception of taste.
Olfactory: are false perceptions of the sense of smell.

11. Diagnostic Criteria 3. Disorganized Speech: (impaired communication)
loose association or derailment: slips from the track from one topic to another
Answers to questions obliquely related or completely unrelated (Tangentiality, circumstantiality)
Incoherent or ward salad, neologisms

12. Diagnostic Criteria 4. Odd behaviors (disorganized behavior)
Child like silliness to unpredictable agitation
May be noted in any form of goal-directed behaviors, leading to difficulties in performing ADL, such as maintaining hygiene, the person may dress in an unusual manner (wearing multiple overcoats, scarves, and gloves in a hot day)
Inappropriate sexual behavior (masturbation in public)
Unpredictable and un-triggered agitation (shouting and swearing)
Strange grimaces, sniffing, blowing out cheeks, wrinkling the forehead, or ritualistic activities–
Mannerism or catatonic--stupor, negativism, rigidity, excitement, waxy flexibility, or posturing –
Immobility, adopting odd postures for long periods of time.

13. 5. Negative symptoms: Diagnostic Criteria
Affective flattening (face immobile, unresponsive, poor eye contact, and reduce and language)
Alogia (poverty of speech lacks content, diminshed )
Avolition (inability to initiate and persist in goal directed activities) absence of interest in usual routines (grooming, hygiene
Anhedonia-inability to experience pleasure (relationships, sex)
Asociality: refers to the apparent lack of interest in social interaction

14. Diagnostic Criteria C. Duration: B. Social \ Occupational Dysfunction:
Marked deterioration in role functioning in one or more of major areas; work or school, interpersonal relations, self care activities.
C. Duration:
Continuous signs persist for at least 6 months. (includes at least one month of acute symptoms, the other period there will be prodromal signs)

16. D. Exclusion of affective disorders
Diagnostic Criteria
D. Exclusion of affective disorders
if affective disorder occur during acute period. it’s period of presence must be short as related to the acute period.
E. Exclusion to any medical or drug use disorder
Such as Alcohol, Cocaine, LSD, Anesthesia, Anti-Cholinergic agents, Chemotherapy, Carbon monoxide, Volatile substances such as Fuel and Paint
F. Not related to any developmental disorder
such as autistic disorder.

18. Associated Features with Schizophrenia
Inappropriate affect
Dysphoria Mood (depressed, anxiety)
Disturbed sleep pattern
Lack of interest in eating or food refusal
Depresonalization
Derealization
Somatic concern (Delusional proportions)
Anxiety and Phobias are common
Deficits in memory (working)

19. Associated Features with Schizophrenia
Deficits in language functions
Abnormalities in sensory processing and inhibitory capacity
Reduction in attention
Social cognition deficits (inability to infer the intentions of other people)
Lack of insight
Hostility and aggression

20. Functional Consequences of Schizophrenia
Schizophrenia is associated with significant social or occupational dysfunction.
Individuals with schizophrenia have impaired educational progress and are unable to maintain employment (due Avolition or other symptoms)
Most individuals are employed at a lower level than their parents.
Most of them don’t marry or have limited contacts outside of their family.

21. CATATONIA
The clinical picture is dominated by three or more of the following symptoms:
One or two of the following symptoms are present for at least two weeks:
Stupor: (marked decrease in reactivity to the environment the person might seem as in coma but still aware about the environment).
Excitement (purposeless motor activity, not influenced by external environment).
Posturing (voluntary assumption and maintenance of inappropriate or bizarre positions)

22. CATATONIA
Negativism: (motiveless resistance to any attempt to move the patient)
Mannerism: (odd movement, goal directed )
Stereotypy: (repetitive, abnormal frequent- not goal directed)
Agitation: not influenced by external stimuli
Echolalia: mimicking another speech
Echopraxia: mimicking another movement
Tends to be severe and quite rare

23. CATATONIA
Posturing: (spontaneous and active maintenance of a posture against gravity)
Rigidity: (maintenance of rigid posture against efforts to be moved)
Waxy flexibility: Slight resistance to positioning by examiner
Catalepsy: (Passive induction of a posture held against gravity
Mutism: (No or very little verbal response exclude aphasia.

24. Schizophrenia: Phases
Phase I: Schizoid personality
Emotional coldness (limited range of emotional expression), Do not enjoy relationships, prefers solitary activities
Not all client who develop schizophrenia has schizoid personality
Phase II: The prodromal phase
Social withdrawal, neglect of hygiene & grooming, blunted or inappropriate affect, bizarre ideas, lack of initiatives, interest or energy.
May last for many years (gradual onset)

25. Schizophrenia: Phases
Phase III: Schizophrenia
Acute episode of signs & symptoms
Phase IV: Residual phase
Periods of remission & exacerbation
Similar to prodromal phase

27. Symptoms of Schizophrenia
Negative (Type II)
Affect - blunted or flat
Alogia - little speech
Avolition
Anhedonia
Agnosia (inability to recognize familiar situations, persons, …)
Social withdrawal
Positive (Type I)
Hallucinations
Delusions
Disorganized
Disorganized speech
Disorganized thought
Disorganized or
catatonic behavior

28. Associated features Acute onset Normal pre-morbid functioning
No family history
Normal functioning during remission
Absence of intellectual impairment
Slow onset
Pre-morbid emotional problems
Family history
Chronic deterioration in social functioning
Intellectual impairments

29. Associated features Normal CT Normal neuro-psychological testing
Good response to antipsychotic medications
Cerebellar atrophy
Abnormal neuropsychological tests
Poor response to antipsychotic medications

30. PREVALENCE
The lifetime prevalence of schizophrenia appears to be 0.3% %.
Schizophrenia occurs in 1 person from 1000 person in the society.
The psychotic features of schizophrenia usually emerge between the late teens and the mid-30s.
The peak onset of schizophrenia is early to mid 20s for males and in the late-20s for females

31. RISK FOR SUICIDE
Approximately 5%-6% of individuals with schizophrenia die by suicide, about 20% attempt suicide on one or more occasions.
Suicidal behavior is sometimes in response to command hallucinations
High risk for young male with comorbid substance use.
Other risk factor include having depressive symptoms or feelings of hopelessness and being unemployed, and the risk is higher, also, in the period after psychotic episode or hospital discharge.

32. OTHER PSYCHOTIC DISORDERS: SCHIZOPHRENIFORM
Two or more of the following, each present for a significant portion of time during a 1 month period. At least one of these must be (1), (2), or (3)
Prodromal, acute, & residual occur at least for one month & less than 6 months
Specify:
Without good prognostic feature
With good prognostic features
Onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual functioning
Confusion or perplexity at the height of the psychotic episode
Good pre-morbid personality
Absence of blunted affect

33. OTHER PSYCHOTIC DISORDERS: SCHIZOAFFECTIVE DISORDER
Uninterrupted period of illness during which the person shows symptoms of mood disorder (depression or mania or mixed) concurrent with Criterion A of schizophrenia
During the period of illness the person has delusions or hallucinations at least 2 weeks in the absence of a major mood episode (manic or depressive)
The person experience symptoms of mood disorder that is relatively brief compared to the total duration of delusion or hallucination episodes
Exclude physical disorder or substance use
Specify:
Bipolar type
Depressive

34. OTHER PSYCHOTIC DISORDERS: Delusional disorder
A. the presence of one or more delusions with a duration of 1 month or longer.
B. Criterion A for schizophrenia has never been met
C. Functioning is not markedly impaired, and behavior is not obviously bizarre or odd
D. if manic or depressive episodes have occurred, these have been brief and relative to the duration of the delusional periods.
E. the disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder.

35. Other psychotic disorders: Delusional disorder
Delusions involve situation that occur in real life and has a specific theme such as:
Erotomanic
Grandiose
Jealousy
Persecutory
Somatic
Mixed

36. OTHER PSYCHOTIC DISORDERS: Brief psychotic Disorder
Presence of 1 or more of the following symptoms. At least one of these must be (1), (2), or (3).
Delusion
Hallucination
Disorganized speech
Grossly disorganized or catatonic behavior
Duration of an episode is at least 1 day but less than 1 month with full return to normal function level
Exclude other psychiatric disorders, substance use or physical problems
Specify:
With marked stressors (brief reactive psychosis)
Without marked stressor
With postpartum onset

37. Schizophrenia Co-morbid Conditions
Depression
Anxiety
Aggression
Substance use disorder 37 37