SCHIZOPHRENIA AND OTHER PSYCHOTIC

DISORDERS
Schizophrenia spectrum and other
psychotic disorders
• Include schizophrenia, other psychotic disorders,
and schizotypal (personality) disorder.
• They are defined 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
•
 SCHIZOPHRENIA
• The broad category of schizophrenia includes
a set of disorders in which individuals
experience:
• Distorted perception of reality and
impairment in thinking.
• Behavior, affect, and motivation.
•
 Cont.:
• Clear consciousness and intellectual
capacity are usually maintained although
certain cognitive deficits may evolve in
the course of time
 Intro- Schizophrenia
• The term schizophrenia was coined in 1908 by
the Swiss psychiatrist Eugen Bleuler.
• Derived from the Greek skhizo (split) and phren
(mind).
• Of all the mental illnesses, schizophrenia
probably is responsible for
• lengthier hospitalizations,
• Greater chaos in family life,
• More exorbitant costs to individuals and governments, and
• More fears than any other.
 4 A‘s” of Bleuler
• Paul Eugene Bleuler was a swiss psychiatrist and
humanist
• He believed that for the diagnosis of
schizophrenia the most important are the four
symptoms:
– Affective blunting
– Autism
– Ambivalence (fragmented emotional
response)
– Alogia – Lack of speech and issues with
verbal fluency caused by disruption in the
thought process.
 Schneider’s First-Rank Symptoms
• The presence of one or more of these is considered
to be strongly suggestive of schizophrenia

1. Hearing one’s thoughts spoken aloud (thought

echo).
2. Hallucinatory voices in the form of statement and
reply (the patient hears voices discussing him in the
third person).
 Cont.:
3. Hallucinatory voices in the form of a running
commentary (voices commenting on one’s
action).
4. Thought withdrawal (thoughts cease and
subject experiences them as removed by an
external force).
 Cont.:
5. Thought insertion (experiencing one’s own thoughts as
someone else’s).
6. Thought broadcasting (characterized by an unshakeable
feeling that people around them can hear their innermost
thoughts.
•7. Delusional perception (unshakable belief in something
that’s untrue.
•Somatic passivity
•Made volition or acts
•Made impulses
•Made feelings or affect
DSM -5 Diagnosis of schizophrenia
• The patient must experience two of the
symptoms:
• One of the symptoms must be:
• Delusions
• Hallucinations
• Disorganized speech
 Diagnosis Cont.:
• Symptoms continue for at least six months
with at least one month of symptoms or less if
successfully treated.
• May include periods of prodromal or residual
 Types of Delusions
Persecutory
Believing that others intend to harm them or that
they’re being accused of doing something horrible
that they never did.

•
•
•
•
 Cont.:
• Jealous and grandiose
• Grandiose - believe that they have a special
destiny, they are more important than other
people, they are immortal, or have
supernatural powers.
• Jealous- May believe that their partner is
cheating on them even when they have no
evidence to suggest infidelity.
•
 Nature of Schizophrenia
• Disturbances in thought processes,
perception, and affect result in a
severe deterioration of social and
occupational functioning.
• Symptoms generally appear in late
adolescence or early adulthood.
 Cont.:
• The pattern of development can be viewed in
four phases:
1. The pre-morbid phase,
2. The prodromal phase,
3. The active psychotic phase
(schizophrenia),and
4. The residual phase
 Cont.:
Pre-morbid personality often indicates:
• Social maladjustment
•Social withdrawal
• Irritability
• Antagonistic thoughts and behavior.
•Very shy and withdrawn
• Poor peer relationships
• Doing poorly in school
•Demonstrating antisocial behavior
 Cont.:
• Prodromal phase of schizophrenia begins with
a change from pre-morbid functioning and
extends until the onset of frank psychotic
symptoms.

• It has an average length of 2 and 5 years

 Frank psychotic symptoms
• Positive symptoms such as hallucinations & delusions
• Negative symptoms such as affective flattening (lack
of spontaneity or reactivity of mood)
• Avolition (lack of drive)
• Anhedonia (lack of pleasure)
• Attention deficit, or impoverishment of speech and
language.
•
 Prodromal phase cont.:
• The person experiences functional impairment
and nonspecific symptoms such as:
• Sleep disturbance
• Anxiety
• Irritability, depressed mood, Poor
concentration, fatigue, and behavioral deficits
such as deterioration in role functioning and
social withdrawal.
 Schizophrenia cont.:
Active phase
The psychotic symptoms are prominent with
Characteristics symptoms such as :
•Delusions
•Hallucinations
•Disorganized speech
•Catatonic behavior
•Negative symptoms
Social/occupational dysfunction:
•Persist for a period not less than 6 months
 Cont.:
Schizoaffective and mood disorder exclusion has
been ruled out
•Substance/general medical condition has been
excluded
 Cont.:
Residual phase
•Symptoms of the acute stage are either absent
or no longer prominent.
•Negative symptoms may remain, and flat affect
and impairment in role functioning are
common.
 Schizophrenia Cont.:
• The most important psychopathological phenomena include
– Thought echo
– Thought insertion or withdrawal
– Thought broadcasting
– Delusional perception and delusions of control
– Influence or passivity
– Hallucinatory voices commenting or discussing the patient in the third
person
– Thought disorders and negative symptoms.
 Clinical Features
• The symptoms of schizophrenia fall into three
broad categories.
Positive Symptoms : unusual thoughts or
perceptions, including hallucinations, delusions,
thought disorder and disorder of movement,
Negative Symptoms: reductions in normal
emotional and behavioral states such as:
Anhedonia: inability to feel pleasure; lack of
interest or enjoyment in activities or
relationships
 Cont.:
Alogia
•lack of meaningful speech, which may take
several forms, including poverty of speech
(reduced amount of speech) or poverty of
content of speech (little information is
conveyed; vague( unfocused) repetitive.
 Clinical Features
Asociality
• Impairments in social relationships; few friends,
poor social skills, little interest in being with other
people
Flat affect
• No stimulus can elicit an emotional response.
Avolition
• Inability or lack of energy to engage in routine
activities.
 Cont.:
Cognitive Symptoms
Often detected when neuropsychological test is
performed.
• Poor executive functioning
• Inability to sustain attention.
• Problems with working memory
Others: ambivalence, association looseness, flight of
ideas, echopraxia, echolalia, perseveration,
catatonia, verbigeration, neologism, mannerism,
etc
 Cont.:
Others cognitive symptoms
• Ambivalence ( mixed feelings)
• Association looseness
Thought process disorder characterized by lack
of connection between ideas.
 Negative symptoms Cont.:
• Flight of ideas
A rapid speech pattern with abrupt topic changes
characterized by loosely connected or unrelated
thoughts.
• Echopraxia
Someone mimics or mirrors someone else’s
movements or behaviors
 Negative symptoms Cont.:
• Echolalia
Repetition of words or phrases spoken by others
• Perseveration
The repetition of a particular response e.g word,
phrase or gesture regardless of the absence or
cessation of stimulus e.g. ( talking about a topic
even when conversation has moved on to other
things.
•
 Negative Symptoms Cont.:
Catatonia – a psychomotor condition.
Characterized by immobility with abnormal
body movements alternating stupor and motor
rigidity, flexibility and sometimes excitability.
 DSM Criteria of Catatonia
• The essential feature of catatonia is a marked
psychomotor disturbance that may involve:
• Decreased motor activity
• Excessive and peculiar motor activity,
decreased engagement during interview or
physical examination.
 Catatonia Cont.:
Defined by the presence of at least three of the
symptoms:
•Stupor
•Catalepsy
•Waxy
•Mutism
•Negativism( opposition to instructions or
external stimuli.
 Symptoms of Catatonia Cont.:
• Posturing
• Mannerism
• Sterotypy ( Non- goal directed movements)
• Agitation
• Grimacing
• Echolalia( Mimicking others speech)
• Echopraxia (mimicking others movements)
 Treatment of Catatonia
• Lorazepam
• Lowest dose 2 mg –Maximum 6 mg/day
• Success rate is 80%
• May experience lorazepam resistance
• ECT (electroconvulsive therapy treatment. It
sends electric current through the brain
• Glutamate modulators ( memantine) may
benefit
 Negative Symptoms of
Schizophrenia Cont.:

Verbigeration- Repeating same word or

sentence against ones will. (May say
nonsense syllable/syllables
Eologism- invention of words to which
meanings are attached ( I through the dish at
the geshinker
• Mannerism, etc
 Subtypes of Schizophrenia

• Disorganized Schizophrenia
• Catatonic Schizophrenia
• Paranoid Schizophrenia
• Undifferentiated Schizophrenia
• Residual Schizophrenia
 Disorganized Schizophrenia
• Disorganized schizophrenia is characterized by
disorganized thinking with blunted and inappropriate
emotions.
• It begins mostly in adolescent age, the behavior is often
bizarre.
• There could be mannerisms, grimacing, inappropriate
laugh and joking.
• There is a tendency for social isolation.
• Usually the prognosis is poor because of the rapid
development of "negative" symptoms, particularly
flattening of affect and loss of volition.
• Hebephrenia should normally be diagnosed only in
adolescents or young adults.
• Denoted also as Hebephrenic schizophrenia
 Catatonic Schizophrenia
• Catatonic schizophrenia is characterized mainly by
motoric activity, which might be strongly increased
(hypekinesis) or decreased (stupor), or automatic
obedience and negativism.
• There are two forms:
– productive form — which shows catatonic excitement,
extreme and often aggressive activity. Treatment by
neuroleptics or by electroconvulsive therapy.
– stuporose form — characterized by general inhibition of
patient’s behavior or at least by retardation and slowness,
followed often by mutism, negativism, fexibilitas cerea or by
stupor. The consciousness is not absent.
 Paranoid Schizophrenia
• Paranoid schizophrenia is characterized mainly by
delusions of persecution, feelings of passive or active
control and feelings of intrusion.
• The delusions are not usually systemized too much,
without tight logical connections and are often
combined with hallucinations of different senses,
mostly with hearing voices.
• Disturbances of affect, volition and speech, and
catatonic symptoms, are either absent or relatively
inconspicuous.
 Undifferentiated Schizophrenia
• Psychotic conditions meeting the general diagnostic
criteria for schizophrenia but not conforming to any
of the subtypes above, or exhibiting the features of
more than one of them without a clear
predominance of a particular set of diagnostic
characteristics.

• This subgroup represents also the former diagnosis

of atypical schizophrenia.
 Residual Schizophrenia
• A chronic stage in the development of schizophrenia

• This category should be used when there has been at

least one episode of schizophrenia in the past but
without prominent psychotic symptoms at present

• Symptoms of residual schizophrenia include

emotional blunting, eccentric behaviour, illogical
thinking, social withdrawal and loosening of
associations.
 Simple Schizophrenia
• Simple schizophrenia is characterized by early and
slowly developing initial stage with growing social
isolation, withdrawal, small activity, passivity,
avolition and dependence on the others.

• The patients are indifferent, without any initiative

and volition. There is not expressed the presence of
hallucinations and delusions.
 Prognosis
Good Poor
1. Abrupt or acute onset Insidious onset
2. Later onset Younger onset
3. Presence of precipitating factor Absence of precipitating factor
4. Good premorbid personality Poor premorbid personality
5. Paranoid and catatonic subtypes Simple, undifferentiated subtypes
6. Short duration: (<6 months) Long duration:(>2 years)

7. Predominance of positive symptoms Predominance of negative symptoms

8. Family history of mood disorders Family history of schizophrenia

9. Good social support Poor social support

10. Female sex Male sex

11. Married Single, divorced or widowed

12. Out-patient treatment Institutionalization

 Other Psychotic Disorders
• Schizotypal Disorder
• Delusional Disorder
• Brief Psychotic Disorder
• Schizoaffective Disorder
• Schizophreniform Disorder
• Shared Psychotic Disorder
• Psychotic Disorder Due to a General Medical
Condition
• Substance-Induced Psychotic Disorder
 Schizotypal Disorder
• DSM-5, schizotypal personality disorder
(STPD) is defined as a “pervasive pattern of
social and interpersonal deficits marked by
acute discomfort with, and reduced capacity
for, close relationships as well as by cognitive
or perceptual distortions and eccentricities of
behavior, beginning by early adulthood
 Delusional Disorders
• Presence of one or more non bizarre delusions that
persist for at least 1 month.
• Hallucinations, if present, are not prominent and are
related to the delusional theme (e.g., the sensation
of being infested with insects associated with
delusions of infestation).
• Apart from the impact of the delusion(s) or its
ramifications, functioning is not markedly impaired,
and behavior is not obviously bizarre or odd.
 Delusions Cont.:
• If manic or major depressive episodes have
occurred, these have been brief relative to the
duration of the delusional periods.
• 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, such as body
dysmorphic disorder or obsessive-compulsive
disorder.
 Types of Delusion
• Erotomanic : Applies when the central theme
of the delusion is that another person is in
love with the individual.
• Grandiose : When the central theme of the
delusion is the conviction of having some
great talent or insight or having made some
important discovery.
 Types of Delusion cont.
Jealous type
This subtype applies when the central theme of
the individual’s delusion is that his or her spouse
or lover is unfaithful.
 Cont.:
Persecutory type
This subtype applies when the central theme of
the delusion involves the individual’s belief that
he or she is being conspired against, cheated,
spied on, followed, poisoned or drugged,
maliciously maligned, harassed, or obstructed in
the pursuit of long-term goals.
 Cont.:
Somatic type
This subtype applies when the central theme of
the delusion involves bodily functions or
sensation
Mixed type
This subtype applies when no one delusional
theme predominates.
 Cont.:
Unspecified type
This subtype applies when the dominant
delusional belief cannot be clearly determined
or is not described in the specific types (e.g.,
referential delusions without a prominent
persecutory or grandiose component).
 Cont.:
Delusions are deemed bizarre
• If they are clearly implausible, not
understandable, and not derived from ordinary
life experiences
Example: An individual’s belief that a stranger
has removed his or her internal organs and
replaced them with someone else’s organs
without leaving any wounds or scars).
•
Acute and Transient Psychotic Disorders

• The criteria should be the following features:

– acute beginning (to two weeks)
– presence of typical symptoms (quickly changing
“polymorphic symptoms”)
– presence of typical schizophrenic symptoms.

• Complete recovery usually occurs within a few

months, often within a few weeks or even days.

• The disorder may or may not be associated with

acute stress, defined as usually stressful events
preceding the onset by one to two weeks.
 Induced Delusional Disorder
• Folie à deux - is a delusional system that develops in a
second person as a result of a close relationship with
another person who already has a psychotic disorder with
prominent delusions
• The person with the primary delusional disorder is usually
the dominant person in the relationship, and the delusional
thinking is gradually imposed on the more passive partner.
• This occurs within the context of a long-term close
relationship, particularly when the couple has been socially
isolated from other people.
 Schizoaffective Disorders
• Schizoaffective disorder is a mental health condition that is
marked by a mix of schizophrenia symptoms, such as:
Hallucinations and delusions.

• Mood disorder symptoms, such as depression, mania and a

milder form of mania called hypomania.
•
 Cont.:
• Patients suffering from periodic schizoaffective disorders,
especially with manic symptoms, have usually good prognosis
with full remissions without any remaining defects.
They are divided in different subgroups
Schizoaffective disorder, manic type
Schizoaffective disorder, depressive type
Schizoaffective disorder, mixed type
Other schizoaffective disorders
Schizoaffective disorder, unspecified
 Schizophreniform Disorder
•Symptoms are identical to those of schizophrenia,
with the exception that the duration, including
prodromal, active, and residual phases, is at least 1
month but less than 6 months.

•The diagnosis is changed to schizophrenia if the

clinical picture persists beyond 6 months.
 Brief Psychotic Disorder
• The essential feature of this disorder is the
sudden onset of psychotic symptoms that may
or may not be preceded by a severe
psychosocial stressor.

• These symptoms last at least 1 day but less

than 1 month, and there is an eventual full
return to the premorbid level of functioning.
 Aetiology
Genetic Factors
• The prevalence rate among family members of schizophrenics
is as follows:
• 1% for normal population
• Children with one schizophrenic parent: 12%
• Children with both schizophrenic parents: 40%
• Siblings of schizophrenic patient: 8%
• Second-degree relatives: 5-6%
• Dizygotic twins of schizophrenic patients: 12%
• Monozygotic twins of schizophrenic patients: 47%
Biochemical Factors
• An excess of dopamine dependent neuronal activity in the
brain may cause schizophrenia
• Others: nor epinephrine, serotonin,acetylcholine and gamma-
aminobutyric acid (GABA)
 Etiology cont.:
Structural Changes in the Brain
• Enlarge ventricles
• Increased loss of gray matter in adolescence
• Shrinkage of cerebellar vermis
• Thicker corpus callosum
Psychological Factors
• Cold, over-protective and domineering mothers
• Dysfunctional family system
• Poor parent-child relationships
• Double-bind communication from parents
• Stressful life events
 Treatment
There is currently no cure for schizophrenia.
• Treatment is aimed at reducing symptoms and preventing
psychotic relapses.
Pharmacology
• Two major types of antipsychotic medications (or neuroleptics):
•CONVENTIONAL or TYPICAL ANTIPSYCHOTICS
Haloperidol
control the positive symptoms very effectively
side effects are Extrapyramidal symptoms that include:
(chronic: tardive dyskinesia, parkinsonism, akathisia;
acute: acute dystonia, neuroleptic malignant syndrome)
High affinity for D2 dopamine receptors
•
• NEWER or ATYPICAL ANTIPSYCHOTICS (clozapine, risperidone, olanzapine,
ziprasidone, quietapine, sertindole)
•  better at treating the negative symptoms
•  milder motor side effects; but others (weight gain, diabetes)
•  they have affinity to multiple receptors
 Cont:

NEWER or ATYPICAL ANTIPSYCHOTICS

• Clozapine, risperidone, olanzapine, ziprasidone,
quietapine, sertindole)
• Better at treating the negative symptoms
• milder motor side effects; but others cause (weight
gain & diabetes)
• They have affinity to multiple receptors
• Electroconvulsive Therapy (ECT)
 Treatment of Schizophrenia
chlorpromazine, chlorprotixene,
clopenthixole, levopromazine, periciazine,
Conventional thioridazine
antipsychotics
droperidole, flupentixol, fluphenazine,
(classical
fluspirilene, haloperidol, melperone,
neuroleptics)
oxyprothepine, penfluridol, perphenazine,
pimozide, prochlorperazine, trifluoperazine

Atypical amisulpiride, clozapine, olanzapine,

antipsychotics quetiapine, risperidone, sertindole, sulpiride
 Drug Dosages
• Chlorpromazine: 300-1500 mg/day PO; 50-100
mg/day IM
• Fluphenazine decanoate: 25-50 mg IM every 1-3
weeks
• Haloperidol: 5-100 mg/day PO; 5-20 mg/day IM
• Trifluoperazine: 15-60 mg/day PO; 1-5 mg/day IM
• Clozapine: 25-450 mg/day PO
• Risperidone: 2-10mg/day PO
 Psychological Therapies
• Group therapy
• Behaviour therapy
• Social skills training
• Cognitive therapy
• Family therapy
 Nursing Diagnoses
• Risk for Other-Directed Violence
• Risk for Suicide
• Disturbed Thought Processes
• Disturbed Sensory Perception
• Disturbed Personal Identity
• Impaired Verbal Communication
• Self-Care Deficits
• Social Isolation
• Deficient Diversional Activity
• Ineffective Health Maintenance
• Ineffective Therapeutic Regimen Management
 Nursing Interventions
• Promoting the safety of patient and others
• Establish therapeutic relationship
• Utilizing therapeutic communication
• Help client cope with socially inappropriate
behaviours
• Teaching self care and proper nutrition
• Teaching social skills
• Medication management
• Establish and maintain reality for the client.
 Nursing Interventions
• Use distracting techniques.
• Teach the client positive self-talk, positive thinking,
• and to ignore delusional beliefs
• Redirect client away from problem situations.
• Deal with inappropriate behaviors in a
nonjudgmental and matter-of-fact manner; give
factual statements; do not scold.
• Try to reintegrate the client into the treatment
milieu as soon as possible.
• Do not make the client feel punished or shunned
for inappropriate behaviors.
• Establishing community support systems and care