MPCE 011-BLOCK 4

Schizophrenia and Other Psychotic Disorders

UNIT 1 : SCHIZOPHRENIA: ETIOLOGY, NEUROCOGNITIVE FUNCTIONING AND INTERPERSONAL

ASPECTS

CONCEPT AND DESCRIPTION OF SCHIZOPHRENIA

Schizophrenia is a severe, psychotic disorder. People who have it may hear voices, see things that are
not there or believe that others are reading or controlling their minds. In men, symptoms usually
start in the late teens and early 20s. They include hallucinations, such as visual hallucinations ( seeing
things which are not there), and auditory hallucinations (hearing things which are not present), and
delusions such as false beliefs that others are plotting or conspiring against them while actually there
is no such thing.

HISTORY OF DIAGNOSIS

The first detailed clinical description of what we now recognize to be schizophrenia was offered in
1810 by John Haslam, the apothecary at the Bethlem Hospital in London, England. Fifty years later,
the Belgian psychiatrist Benedict Morel. He used the term démence précoce (mental deterioration at
an early age) to describe the condition and to distinguish it from the dementing disorders associated
with old age. It is the German psychiatrist Emil Kraepelin (1856–1926) who is best known for his
careful description of what we now regard as schizophrenia. Kraepelin used the Latin version of
Morel’s term (dementia praecox) to refer to a group of conditions that all seemed to feature mental
deterioration beginning early in life.

ORIGIN OF THE TERM

Swiss psychiatrist named Eugen Bleuler (1857– 1939) gave the diagnostic term still used today.
Bleuler (1908) identified four fundamental symptoms of what he termed the group of schizophrenias
(literally, ‘split mind’): ambivalence, disturbance of association, disturbance of mood and a
preference for fantasy over reality. In 1911, Bleuler used schizophrenia (from the Greek roots of
sxizo, pronounced “schizo” and meaning “to split or crack,” and phren, meaning “mind”) because he
believed the condition was characterized primarily by disorganization of thought processes, a lack of
coherence between thought and emotion, and an inward orientation away (split off) from reality.
DIAGNOSTIC CRITERIA OF SCHIZOPHRENIA FOLLOWING DSM IV-TR

CLINICAL FEATURES

It is characterised by a constellation of distinctive and predictable symptoms.

The symptoms that are most commonly associated with the disease are called positive symptoms,
that denote the presence of grossly abnormal behaviour.

These include thought disorder, delusions, and hallucinations.

Thought disorder is the diminished ability to think clearly and logically. Often it is manifested by
disconnected and nonsensical language that renders the person with schizophrenia is incapable of
participating in conversation, contributing to the person’s alienation from his family, friends, and
society.

Delusions are common among individuals with schizophrenia. An affected person may believe that
he is being conspired against (called “paranoid delusion”). Broadcasting, describes a type of delusion
in which the individual with this illness believes that his thoughts can be heard by others.

Hallucinations are perceptual disorder, in which one could suffer from auditory hallucination, visual
hallucination and tactile hallucination. Sometime the voices that the schizophrenic hears may
describe the person’s actions, warn him of danger or tell him what to do. At times the individual may
hear several voices carrying on a conversation.

Less obvious than the “positive symptoms” but equally serious are the deficit or negative symptoms
that represent the absence of normal behaviour. These include flat or blunted affect (i.e. lack of
emotional expression), apathy, and social withdrawal).
Schizophrenia is a mental disorder characterised by a disintegration of thought processes and of
emotional responsiveness. It most commonly manifests as auditory hallucinations, paranoid or
bizarre delusions, or disorganised speech and thinking, and it is accompanied by significant social or
occupational dysfunction.

ETIOLOGY OF SCHIZOPHRENIA

Genetics

Genetic vulnerability and environmental factors can act in combination to result in diagnosis of
schizophrenia. Research suggests that genetic vulnerability to schizophrenia is multi factorial, caused
by interactions of several genes.

Both individual twin studies and meta analyses of twin studies estimate the heritability of risk for
schizophrenia to be approximately 80%. Concordance rates between monozygotic twins was close to
50%, whereas dizygotic twins was 17%. Adoption studies have also indicated a somewhat increased
risk in those with a parent with schizophrenia even when raised apart.

Prenatal

It is well established that obstetric complications or events are associated with an increased chance
of the child later developing schizophrenia, although overall they constitute a non specific risk factor
with a relatively small effect.

Fetal Growth

Lower than average birth weight has been one of the most consistent findings, indicating slowed
fetal growth possibly mediated by genetic effects. Almost any factor adversely affecting the fetus will
affect growth rate, however, so the association has been described as not particularly informative
regarding causation. In addition, the majority of birth cohort studies have failed to find a link
between schizophrenia and low birth weight or other signs of growth retardation.

Hypoxia

It has been hypothesized since the 1970s that brain hypoxia (low oxygen levels) before, at or
immediately after birth may be a risk factor for the development of schizophrenia. Hypoxia is now
being demonstrated as relevant to schizophrenia in animal models, molecular biology and
epidemiology studies.

Other Factors

There is an emerging literature on a wide range of prenatal risk factors, such as prenatal stress,
intrauterine (in the womb) malnutrition, and prenatal infection. Increased paternal age has been
linked to schizophrenia, possibly due to “chromosomal aberrations and mutations of the aging
germline.”

Maternal-fetal rhesus or genotype incompatibility has also been linked, via increasing the risk of an
adverse prenatal environment. Also, in mothers with schizophrenia, an increased risk has been
identified via a complex interaction between maternal genotype, maternal behaviour, prenatal
environment and possibly medication and socio-economic

factors.

Infections
Numerous viral infections, in utero or in childhood, have been associated with an increased risk of
later developing schizophrenia.

Influenza has long been studied as a possible factor. A 1988 study found that individuals who were
exposed to the Asian flu as second trimester fetus were at increased risk of eventually developing
schizophrenia. Polio, measles, varicella-zoster, rubella, herpes simplex virus type 2, maternal genital
infections, Borna disease virus, and more recently Toxoplasma gondii, have been correlated with the
later development of schizophrenia.

Childhood Antecedents

Overall, birth cohort studies have indicated subtle nonspecific behavioural features, some evidence
for psychotic like experiences (particularly hallucinations), and various cognitive antecedents. There
have been some inconsistencies in the particular domains of functioning identified and whether they
continue through childhood and whether they

are specific to schizophrenia.

Substance abuse, childhood adversities, complex urban life and societal demands, and personality
dispositions can have a role in the development of this disease.

NEUROCOGNITIVE FUNCTIONING ASPECTS IN SCHIZOPHRENIA

On the basis of localised neuropsychological tests, various authors have concluded that
schizophrenia is characterised by cognitive test profiles indicative of dysfunction of the frontal lobe,
temporal lobe, left or right

hemisphere, basal ganglia, etc. This lack of consensus may reflect the heterogeneity of schizophrenia,
and may also be a result of the relatively poor localising ability of many standard neuropsychological
instruments. A variety of brain regions and associated cognitive functions have thus been implicated
in the psychopathology that characterises schizophrenia.

In general, the strongest camps to emerge have been those that claim a disproportionate
impairment of memory functioning and relatively selective executive dysfunction. Others have
reported more widespread neuropsychological dysfunction.

The resulting cognitive data were subjected to cluster analysis and five cognitive clusters

emerged:

selective executive dysfunction;

normative function;

executive and motor deficits;

dementia/multi-focal disturbance; and

relatively selective motor deficits.

Heinrichs & Awad (1993) proposed that cluster analysis of cognitive test data may thus have promise
in reducing and clarifying the heterogeneity of schizophrenia, and concluded that several patterns of
neurocognitive dysfunction may underlie schizophrenia, thus contributing to the heterogeneity of
the illness and its variable functional outcome.
Frith (1992) has also proposed a fascinating theoretical model, where he relates specific signs and
symptoms to particular information processing abnormalities.

TREATMENT OF SCHIZOPHRENIA

HOSPITALIZATION

MEDICATION

COGNITIVE-BEHAVIOURAL THERAPY

META COGNITIVE THERAPY

FAMILY THERAPY

UNIT 2 : PARANOID AND DELUSIONAL DISORDER

CLINICAL PICTURE AND DIAGNOSIS

paranoia is a medical illness, which happens to affect the brain, and causes changes in thinking and
feeling. Those with the condition are hypersensitive, are easily slighted, and habitually relate to the
world by vigilant scanning of the environment for clues or suggestions to validate their prejudicial
ideas or biases.

The main symptom of paranoia is permanent delusion. It should be kept in mind that there is
delusion in schizophrenia also but in that case it is not permanent or organised. In paranoia the
symptoms of delusion appear gradually, and the patient is sentimental, suspicious, irritable,
introverted, depressed, obstinate, jealous, selfish, unsocial and bitter. Hence his social and family
adjustment is not desirable, and while he has the highest desirable, the effort that he is prepared to
expend is correspondingly little.

Delusions are irrational beliefs, held with a high level of conviction, that are highly resistant to
change even when the delusional person is exposed to forms of proof that contradict the belief.

Non-bizarre delusions are considered to be plausible; that is, there is a possibility that what the
person believes to be true could actually occur a small proportion of the time. Conversely, bizarre
delusions focus on matters that would be impossible in reality.

DELUSIONS AND OTHER DISORDERS

Delusions are often observed in persons with other psychotic disorders such as

schizophrenia and schizoaffective disorder. In addition to occurring in the psychotic

disorders, delusions also may be evident as part of a response to physical, medical

conditions (such as brain injury or brain tumors), or reactions to ingestion of a drug.

Delusions also occur in the dementias, which are syndromes wherein psychiatric

symptoms and memory loss result from deterioration of brain tissue. Because delusions

can be shown as part of many illnesses, the diagnosis of delusional disorder is partially

conducted by process of elimination

SYMPTOMS AND PERSONALITY

Distrust is the hallmark of delusional disorder. Someone who suffers from this disorder

is very defensive, sometimes to the point of being aggressive, and may constantly question the
motives of others. Even if people appear harmless on the surface, the patient believes that they are
simply trying to lull the patient into a sense of complacency, and the patient will remain on guard as
a result. Other symptoms of delusional disorder can include a sense of social isolation caused in part
by the patient’s defensive and suspicious behaviour, and a lack of humor.

TYPES

DELUSION OF GRANDEUR

DELUSION OF PERSECUTION

ERATOMANIC DELUSION

CAUSAL FACTORS

BIOLOGICAL & HEREDITORY

PERSONALITY DISPOSITION

EMOTIONAL COMPLEX

DYSFUNCTIONAL COGNITIVE PROCESSING

SUBSTANCE ABUSE

MEDICAL CONDITIONS

OTHER MENTAL ILLNESS

ENVIRONMENTAL

TREATMENT

MEDICATION

Antipsychotic medication such as thioridazine (Mellaril),haloperidol (Haldol),

chlorpromazine (Thorazine), clozapine (Clozaril), or risperidone (Risperdal) may be

Prescribed.

PSYCHOTHERAPY

Individual psychotherapy: Can help the person recognise and correct the underlying thinking that has
become distorted.

Cognitive behavioural therapy (CBT): Can help the person learn to recognise and

change thought patterns and behaviours that lead to troublesome feelings.

Family therapy: Can help families deal more effectively with a loved one who has

delusional disorder, enabling them to contribute to a better outcome for the person.
UNIT 3

PSYCHOTIC DISORDER DUE TO GENERAL MEDICAL CONDITION

CLINICAL PICTURE

psychosis caused by a medical condition may be a single isolated incident or may be recurrent,
cycling with the status of the underlying medical condition. Although treating the medical condition
often results in the remission of the psychosis.

The symptoms of psychosis sometimes persists long after the medical conditions and caused
psychosis. Prominent hallucinations and delusions are the main cause for such psychotic
development. Individuals with brief psychotic disorder experience delusions, hallucinations, and/or
disorganised speech and behaviour that lasts for at least one day.

However, these symptoms remit within one month, and their behaviour returns to normal. If the
observed psychotic symptoms can be reasonably thought to have been due to a pre-existing mental
illness diagnosis .

Types of Psychotic Disorders

According to the Diagnostic and Statistical Manual of Mental Disorders (2000), text revision (DSM IV
TR), there is not an universal acceptance of the term psychotic, however the DSM IV TR definition
refers to the existence of specific symptoms such as delusions, prominent hallucinations,
disorganised speech, disorganised or catatonic behaviour. There are various types of disorders under
this category.

Schizophrenia: People with this illness have changes in behaviour and other symptoms — such as
delusions and hallucinations — that last longer than six months, usually with a decline in work,
school and social functioning.

Schizoaffective disorder: People with this illness have symptoms of both schizophrenia and a mood
disorder, such as depression or bipolar disorder.

Schizophreniform disorder: People with this illness have symptoms of schizophrenia, but the
symptoms last more than one month but less than six months.

Brief psychotic disorder: People with this illness have sudden, short periods of psychotic behaviour,
often in response to a very stressful event, such as a death in the family. Recovery is often quick —
usually less than a month.

Delusional disorder: People with this illness have delusions involving real-life situations that could be
true, such as being followed, being conspired against or having a disease. These delusions persist for
at least one month.

Shared psychotic disorder: This illness occurs when a person develops delusions in the context of a
relationship with another person who already has his or her own delusion(s).

Substance-induced psychotic disorder: This condition is caused by the use of or withdrawal from
some substances, such as alcohol and crack cocaine, that may cause

hallucinations, delusions or confused speech.

Psychotic disorder due to a medical condition: Hallucinations, delusions or other symptoms may be
the result of another illness that affects brain function, such as a head injury or brain tumor.

CAUSES

A wide variety of central nervous system diseases, from both external poisons and internal
physiologic illness, can produce symptoms of psychosis.

Trauma and stress can cause a short-term psychosis (less than a month’s duration) known as brief
psychotic disorder.

Major life-changing events such as the death of a family member or a natural disaster have been
known to stimulate brief psychotic disorder in patients with no prior history of mental illness. The
source of stress can be from typical events encountered by many people in the course of a lifetime,
such as being widowed or divorced.

Psychosis may also be triggered by an organic cause, termed a psychotic disorder due to a general
medical condition. Organic sources of psychosis include neurological conditions (for example,
epilepsy and cerebrovascular disease), metabolic conditions (for example, porphyria), endocrine
conditions (for example, hyper- or hypothyroidism), renal failure, electrolyte imbalance, or
autoimmune disorders. Common such underlying medical conditions are: thyroid disease with too
much or too little thyroid hormone production; brain tumor; stroke; infection of central nervous
system; epilepsy; liver or kidney disease; systemic lupus erythematosus with central nervous system
involvement; severe fluid and electrolyte disturbances; metabolic conditions affecting blood sugar or
oxygen content of the blood.

Psychoactive Drugs

Various psychoactive substances (both legal and illegal) have been implicated in causing,
exacerbating, and/or precipitating psychotic states and/or disorders in users.

Postpartum Psychosis

In some susceptible women, dramatic hormonal changes in childbirth and shortly afterward can
result in a form of brief psychotic disorder often referred to as postpartum psychosis. Unfortunately,
postpartum conditions are often misidentified and improperly treated. In many cases of a mother
killing her infant or committing suicide , postpartum psychosis is involved.

Persons with personality disorders appear to be more susceptible to developing brief psychotic
reactions in response to stress.

Many cultures have some form of mental disorder that would meet criteria for brief psychotic
disorder the features of which are unique to that culture, wherein most sufferers have similar
behaviours that are attributed to causes that are localised to that community. The DSMIV-TR calls
disorders unique to certain societies or groups “culture-bound.”

TREATMENT

Early Intervention

Hospitalisation

Medications

Antipsychotic medications commonly prescribed to treat psychosis include risperidone

(Risperdal), thioridazine (Mellaril), halperidol (Haldol), chlorpromazine (Thorazine),

clozapine (Clozaril), loxapine (Loxitane), molindone hydrochloride (Moban), thiothixene (Navane),

and olanzapine (Zyprexa). Possible common side-effects of antipsychotics include dry mouth,
drowsiness, muscle stiffness, and hypotension. More serious side effects include tardive dyskinesia
(involuntary movements of the body) and neuroleptic malignant syndrome (NMS), a potentially fatal
condition characterised by muscle rigidity, altered mental status, and irregular pulse and blood
pressure.

Psychosocial Therapy

Psychosocial therapy is considered the most effective in dealing with social, psychological

and behavioural problems resulting from schizophrenia. Therapy includes rehabilitation which helps
an individual to focus on skills and training to help an individual to be independent. Family therapy
enables a person to interact and effectively deal with the family members

UNIT 4 : SUBSTANCE INDUCED PSYCHOTIC DISORDER

DEFINITION AND DIAGNOSTIC CRITERIA

Substance-induced psychotic disorder: This condition is caused by the use of or withdrawal from
some substances, such as alcohol and crack cocaine, that may cause hallucinations, delusions or
confused speech.

The following diagnostic criteria must be met before a diagnosis of Substance Induced Psychotic
Disorder is warranted. According to the DSM IV TR the symptoms must be

a) Prominent hallucinations or delusions

b) Evidence from the history, physical examination, or laboratory findings of either

(1) or (2) given below.

1) The symptoms in Criterion A developed during, or within a month of, substance intoxication or
withdrawal

2) Medication use is etiologically related to the disturbance

c) The disturbance is not better accounted for by a Psychotic Disorder that is not substance induced.

SUBTYPES

With Delusions: This subtype is used if delusions are the predominant symptom.

With Hallucinations: This subtype is used if hallucinations are the predominant symptom.

The context of the development of the psychotic symptoms may be indicated by using

one of the specifiers listed below:

With Onset During Intoxication: This specifier should be used if criteria for intoxication

with the substance are met and the symptoms develop during the intoxication syndrome.

With Onset During Withdrawal: This specifier should be used if criteria for withdrawal
from the substance are met and the symptoms develop during, or shortly after, a withdrawal
syndrome.

A substance induced psychotic disorder that begins during substance use can last as

long as the drug is used. A substance induced psychotic disorder that begins during

withdrawal may first manifest up to four weeks after an individual stops using the

substance.

The speed of onset of psychotic symptoms varies depending on the type of substance.

For example, using a lot of cocaine can produce psychotic symptoms within minutes.

On the other hand, psychotic symptoms may result from alcohol use only after days or

weeks of intensive use.

CAUSES

A large number of toxic or psychoactive substances can cause psychotic reactions.

Such substance induced psychosis can occur in multiple ways.

These include the following:

1) People may inadvertently ingest toxic substances by accident, either because they do not know
any better or by mistake.

2) People may take too much of a legitimately prescribed medicine, medicines may

interact in unforeseen ways. Doctors may miscalculate the effects of medicines they prescribe.

3) People may overdose on recreational drugs they commonly use (such as cocaine), or become
dependent on drugs or alcohol and experience psychotic symptoms while in withdrawal from those
substances.

4) While the substance induced psychosis is triggered and then sustained by intoxication or
withdrawal, its effects can continue long after intoxication or withdrawal has ended.

5) Drugs of abuse that can cause psychosis include alcohol, amphetamines, marijuana, cocaine,
hallucinogens, inhalants, opioids, and sedative-hypnotics, including medicines that are sometimes
used to treat anxiety.

6) Common over the counter and doctor prescribed medications that can cause psychosis include
anesthetics, analgesics, anticholinergic agents, anticonvulsants, antihistamines, cardiovascular
medications, antimicrobial medications, antiparkinsonian medications, chemotherapeutic agents,
corticosteroids, gastrointestinal medications, muscle relaxants, nonsteroidal anti inflammatory
medications like ibuprophin, and anti-depressants.

7) Environmental toxins reported to induce psychotic symptoms include anticholinesterase,

organophosphate insecticides, nerve gases, carbon monoxide (car exhaust), carbon dioxide, and
volatile substances such as fuel or paint.

TREATMENTS

Psychiatric hospitalisation
Antipsychotic medication

Counselling

The goals of substance abuse counselling are:

1) Achieving and maintaining abstinence from alcohol or other drugs of abuse or, for patients unable
or unwilling to work toward total abstinence, reducing the amount and frequency of use and
concomitant biopsychosocial sequelae associated with drug use disorders.

2) Stabilizing acute psychiatric symptoms.

3) Resolving or reducing problems and improving physical, emotional, social, family, interpersonal,
occupational, academic, spiritual, financial, and legal functioning.

4) Working toward positive lifestyle change.

5) Early intervention in the process of relapse to either the addiction or the psychiatric

disorder.

Counseling (supportive therapy) should be initiated, along with patient education to

explain the dangers of huffing. Evaluate patients for psychiatric comorbidity.

Interventions include the following:

) Motivating patients to seek detoxification or inpatient treatment if symptoms

warrant, and sometimes facilitating an involuntary commitment for psychiatric care.

2) Educating patients about psychiatric illness, addictive illness, treatment, and the

recovery process.

3) Supporting patients’ efforts at recovery and providing a sense of hope regarding

positive change.

4) Referring patients for other needed services (case management, medical, social,

vocational, economic needs).

5) Helping patients increase self awareness so that information regarding dual disorders

can be personalised.

6) Helping patients identify problems and areas of change.

7) Helping patients develop and improve problem solving ability and develop recovery

coping skills.

8) Facilitating pharmacotherapy evaluation and compliance. (This requires close

collaboration with the team psychiatrist.)