1. Psychotic Disorders

2. Archetype Schizophrenia

3. Phenomenology The mental status exam The mental status exam Appearance Appearance Mood Mood Thought Thought Cognition Cognition Judgment and Insight Judgment and Insight

4. Appearance Motor disturbances Motor disturbancesCatatoniaStereotypyMannerisms Behavioral problems Behavioral problemsHygiene Social functioning “Soft signs” “Soft signs”

5. Mood and Affect Affective flattening Affective flattening Anhedonia Anhedonia Inappropriate Affect Inappropriate Affect

6. Thought Thought Process Thought Process Content Content

7. Thought Process Associative disorders Associative disorders Circumstantial Thinking Circumstantial Thinking Tangential thinking Tangential thinking

8. Other associative problems PerseverationDistractibilityClangingNeologisms

9. Thought Content Phenomenology Thought content HallucinationsDelusions

10. Cognitions Subtle impairments Frontal lobe function Frontal lobe function Associative thinking

11. Positive versus Negative Sxs Positive Hallucinations Hallucinations Delusions Delusions Bizarre behavior Bizarre behavior Associative disorders Associative disorders

12. Negative Symptoms Alogia Affective flattening AnhedoniaAvolition/apathy

13. Epidemiology

14. Epidemiology ~1% prevalence Genders Age of onset Age of onsetSocioeconomic

15. Pathology

16. Anatomic Widened ventricles Decreased size certain regions

17. Histology Abnormalities of cytoarchitecture Alignment Alignment Amount Amount

18. Pathology Neurophysiology Hypofrontality Hypofrontality

19. More Neurophysiology Other neurological changes Other neurological changes Eye movements Eye movements Blink rate Blink rate Sleep disorders Sleep disorders

20. Etiology Dopamine

21. Dopamine Hypothesis Metabolites Dopamine receptor agonists Action of antipsychotics

22. Other Transmitters Glutamate Primary excitatory transmitter Primary excitatory transmitter May relate to glutaminergic tone May relate to glutaminergic tone NMDA receptor antagonists NMDA receptor antagonistsPCP

23. Neurodegenerative theories Evidence for cell loss Evidence for cell loss Reduced neuronal densities Reduced neuronal densities Etiology Etiology

24. Neurodevelopmental Theories Abnormalities of cytoarchitecture Absence of gliosis

25. Genetics Genetic Theories Family studies 1 o relatives = 5% 1 o relatives = 5% Dizygotic twins = 10% Dizygotic twins = 10% Monozygotic twins = 50% Monozygotic twins = 50% Adoption studies Greater risk Greater risk

26. Possible Environmental Culprits Bad parenting Social/economicViralAllergic/Antibodies

27. Etiology

28. Diagnosis

29. Diagnosis Schizophrenia: DSM-IV “A” Criteria = Psychosis = PsychosisDuration 6 months 6 months Global Criteria

30. Diagnosis “A Criteria” Two or more: Two or more:DelusionsHallucinations Disorganized speech Disorganized behavior Negative symptoms

31. Schizophrenia Subtypes Catatonic Movement MovementDisorganized Process ProcessParanoid Content ContentUndifferentiatedResidual

32. Differential DeliriumDementiaMedication-induced Other Psychiatric Illnesses

33. Comorbidity Depression Substance Abuse

34. Course and Prognosis

35. Course of Schizophrenia

36. Prognosis Usually deteriorates ~ exacerbations w/ incomplete recovery Symptoms change over time

37. Outcome

38. Positive Predictors Acute onset Short duration Good premorbid functioning Affective symptoms Good social functioning High social class Neg fam hx psychotic No structural

39. Poor Predictors Insidious onset Long duration Family hx of psych illness Obsessions/Compulsions Assaultive Behavior Poor premorbid functioning Neurological/anatomic abn. Low social class

40. Treatment

41. Antipsychotic Medications Phenothiazines Chlorpromazine ChlorpromazineButyrophenones Haloperidol HaloperidolAtypicals Clozapine Clozapine

42. Antipsychotics Mechanism of actions Dopamine blockade Dopamine blockade D-2 and analogues D-2 and analogues

43. Antipsychotics: Indications Acute psychosis Prevention of relapse Also used in other disorders Acute mania Acute mania Anxiety/insomnia Anxiety/insomnia Aggressive disorders Aggressive disorders

44. Antipsychotics: Side Effects Anticholinergic Extrapyramidal (Parkinson’s-like)

45. Other effects Dopaminergic Tardive dyskinesia Tardive dyskinesia NMS NMSIdiopathic Hematologic HematologicClozapine Rashes, skin pigmentary, temperature dysregulation Rashes, skin pigmentary, temperature dysregulation

46. Antipsychotics Approach Lower doses usually adequate Lower doses usually adequate Adjust to side effects Adjust to side effects Evaluate for TD Evaluate for TD How long? 1 st episode 1 st episode Maintenance Maintenance

47. Other Treatments Electroshock Other tranquilizers

48. Psychosocial Treatments SupportiveSocial/educativeFamily

49. Other Diagnosis SchizophreniformSchizoaffective Brief Psychotic Delusional Disorders Shared Psychoses Psychosis due to somethin’ else