pschotic disoder.pptxbbbbbbbbbbbbbbbbbbbbb

1
Psychotic Disorders
(For 3rd
year BSc. midwifery students)
By Takele T (MSc, assist professor, PhD candidate)
08/27/2024

08/27/2024 2
Objectives
Describe the concept psychosis –acute and
chronic
Discuss each psychotic disorders and Explain
the difference and similarity between them
List differential diagnosis for each psychotic
disorders
Plan management

3
Definition of Psychosis
Psychotic means grossly impaired reality testing.
With gross impairment in reality testing:
persons incorrectly evaluate the accuracy of their
perceptions and thoughts
Hallucinations, delusions, bizarre behavior, and
incoherent speech are considered direct evidence of
psychosis.
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Types of psychotic disorders
 Schizophrenia
 Schizophreniform Disorder
 Schizoaffective Disorder
 Delusional Disorder
 Brief Psychotic Disorder
 Shared Psychotic Disorder
 Substance induced psychotic disorders
 Psychotic Disorder due to general medical
condition
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What is schizophrenia
 Schizophrenia is a serious brain disorder that
distorts the way a person thinks, acts, expresses
emotions, perceives reality, and relates to others..
 The expression of these manifestations varies
across patients and over time, but the effect of the
illness is always severe and is usually long lasting.
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DX
 Based on the psychiatric history and mental status
examination (MSE).
 There is no laboratory test for schizophrenia
 No clinical sign or symptom is pathognomonic for
schizophrenia; every sign or symptom seen in
schizophrenia occurs in other psychiatric and
neurological disorders.
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Epidemiology
 The lifetime prevalence of
schizophrenia is about 1 percent
 Schizophrenia is found in all societies
and geographical areas, and incidence
and prevalence rates are roughly equal
worldwide.
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Epid….
Gender and Age
 Schizophrenia is equally prevalent in men and women.
 Onset is earlier in men than in women.
 The peak ages of onset are 10 to 25 years for men and 25
to 35 years for women.
 Onset of schizophrenia before age 10 or after age 60 is
extremely rare. 08/27/2024

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Clinical Picture
DSM-V (Diagnostic and Statistical Manual APA)
A-Characteristic symptoms: Two (or more) 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 behavior
negative symptoms, i.e., affective flattening, alogia,
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Cont….
B-Social/occupational dysfunction:
C-Duration: 6months
D-Schizoaffective and mood disorder exclusion:
E-Substance/general medical condition exclusion:
F- Not relationship to a pervasive developmental disorder
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Symptoms of Schizophrenia
Positive symptoms :are exaggerated behaviors
◦ delusions,
◦ hallucinations,
◦ disorganized speech, bizarre behavior.
Negative symptoms :loss of behaviors such as
◦ loss of affect,
◦ inability to maintain social contacts
◦ impaired decision making and inability to maintain
attention.
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Positive symptoms the word positive does not mean
"good." Rather, it refers to obvious symptoms that are
not present in people without schizophrenia
Negative symptoms the word negative does not mean
"bad," but reflects the absence of certain normal
behaviors in people with schizophrenia
Positive symptoms are generally more responsive to
treatment than negative symptoms
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Etiology
 “multifactorial = genetic + environmental factors”
◦ Environmental factors
 Biological factors  prenatal and post natal
complications such as maternal infections and
obstetric complications associated with hypoxia
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Genetics
Prevalence in General population = 1%
Non twin siblings of schizophrenia patient = 8%
Child with one parent with schizophrenia = 12%
Di zygotic twin of a schizophrenia patient = 12%
Child with two parent with schizophrenia = 40%
Mono zygotic twin of schizophrenia patient = 47%

08/27/2024 15
.
The revised dopamine hypothesis suggested that
 the positive symptoms of schizophrenia were likely
due to increases in dopamine activity in the
mesolimbic areas of the brain, particularly in the
nucleus accumbens (most likely involving D2 and
D3 receptors)
 the negative symptoms were thought to be
associated with a decrease in dopamine in the
mesocortical region and/or prefrontal cortices (PFC),
possibly linked more to D1 and/or D4 receptors

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FOUR DOPAMINE PATHWAYS IN THE BRAIN
(i) Nigrostrial Pathway: Substantia Nigra to
Basal Ganglia (movement)
(ii) Mesolimbic Pathway: Venteral Tegmental
Area (VTA) of the Brainstem to Limbic
Systems of the Brain (Positive schizophrenia
symptoms)

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(iii) Mesocortical Pathway: VTA to Frontal
Cortex (Negative &Cognitive
schizophrenia symptoms)
(iv) Tuberoinfundibular Pathway:
Hypothalamus to Anterior Pituitary
Gland (Prolactin secretion)

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Sub-Types of Schizophrenia
1. Paranoid Subtype
 Pre-occupation with one or more
delusions of persecutions or grandeur
 Frequent auditory hallucinations

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First episode of illness at an older age
Show less regressions of their mental
faculties, emotional responses and behaviors
than the other types do.
Comparing to other sub-types paranoid type
show better outcome

08/27/2024 21
2. Disorganized Subtype
Disorganized thought, speech, and behaviour
Affective flattening
Marked regression to primitive /childhood state
Onset before the age of 25
Poor outcome

08/27/2024 22
3. Catatonic Subtype
Marked disturbance of motor activity that is apparently
purposeless and not influenced by external stimuli
Motoric immobility evidenced by stupor, waxy
flexibility Negativism, rigidity
Peculiarities of voluntary movement e.g. mannerisms
Echolalia or echopraxia
Two of the above symptoms are required.

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4. Undifferentiated Subtype
Criterion A symptoms are present, but the
criteria are not met for the paranoid,
disorganized, or catatonic behavior.

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5. Residual Subtype
Presence of continuing evidence of
schizophrenia symptoms in the absence of
active symptoms.
Presence of Emotional blunting, social
withdrawal, odd beliefs.

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Differential diagnosis
 Brief Psychotic disorder
 Schizophreniform disorder
 Schizoaffective disorder
 Delusional disorder
 Mood disorders
 Personality disorder
 Malingering, Factitious disorder
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Prognosis
A reasonable estimate is that 20 to 30 percent of all
schizophrenia patients are able to lead some what
normal lives.
About 20 to 30 percent of patients continue to
experience moderate symptoms, and
40 to 60 percent of patients remain significantly
impaired by their disorder for their entire lives.
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Treatment….
Antipsychotics diminish psychotic
symptom expression and reduce relapse
rates.
Approximately 70 percent of patients
treated with any antipsychotic achieve
remission.
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Phases of Treatment in Schizophrenia
 Treatment of Acute Psychosis
 focuses on alleviating the most severe psychotic symptoms.
 lasts from 4 to 8 weeks.
 Treatment During Stabilization and
Maintenance Phase
 to prevent psychotic relapse and to assist patients in
improving their level of functioning.
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08/27/2024 29
Typical/classicaL Neuroleptics
 Low potency:
◦ Chlorpromazine
◦ Thioridazine
 High potency:
◦ Haloperidol
◦ Fluphenazine

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Atypical Antipsychotics:
 Risperidone
 Olanzapine
 Quetiapine
 Clozapine

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Conventional antipsychotics
Generic name
 Chlorpromazine
(Thorazine)
 Fluphenazine (Prolixin)
 Haloperidol (Haldol)
 Loxapine (Loxitane)
 Mesoridazine (Serentil)
 Perphenazine (Trilafon)
 Thiorizadine (Mellaril)
 Thiothixene (Navane)
 Trifluoperazine
(Stelazine)
Daily Oral Dose Range
 200-1500
 2-20
 2-20
 20-200
 50-400
 4-48
 200-800
 2-30
 5-50
08/27/2024

08/27/2024 32
Neuroleptic (typicals):
side effects
 Acute dystonia
 Akathisia
 Tardive dyskinesia
 Sedation, anticholinergic, lower seizure
threshold, increased prolactin

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Atypical Antipsychotics: Side Effects
 Sedation
 Hyperglycemia, new-onset diabetes
 Anticholinergic effects
 Less prolactin elevation
 Some EPS
 Increased lipids

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Medication-Related Movement Disorders:
Acute Syndromes
 Can occur in 90% of all patients
 Dystonia: involuntary muscle spasms, abnormal postures
 Parkinsonism: rigidity, akinesia (slow movement), and
tremor, masklike face, loss of spontaneous movements
 Akathisia: Inability to sit still, subjective restlessness
 Treatment
◦ Anticholinergic Medication for dystonia, parkinsonism (Artane and
Cogentin)
◦ Akathisia does not usually respond to anticholinergic medication.
Beta blockers have best success.
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Movement Disorders: Chronic
 Tardive Dyskinesia
◦ Irregular, repetitive involuntary movements of
mouth, face, and tongue, Abnormal finger
movements are common.
◦ Begin after 6 months, but also as antipsychotics are
withdrawal
◦ Irreversible - controversy
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Movement Disorders: Chronic
 Etiology
◦ believed that chronic dopamine suppression in the EPS
causes an overactivation of the system
◦ increases in antipsychotic meds, suppresses
 Treatment
◦ prevention by using lowest possible dosage, minimize use
of PRN, closely monitor individuals in high-risk groups
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Neuroleptic Malignant Syndrome(NMS)
It is a life-threatening complication of antipsychotic
treatment.
 The symptoms include
◦ severe muscle rigidity
◦ mutism, agitation,
◦ high fever,
◦ sweating, increased blood pressure
◦ tachycardia.
 Treatment is supportive
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Long-acting injectable (depot)
antipsychotics
 haloperidol and fluphenazine
 risperidone,
 olanzapine
 Injections every 2 weeks or 4 weeks
 Goal is to decrease non-adherence and thus reduce
relapse
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Updated APA Practice Guidelines for
Treatment of Schizophrenia
guideline recommends that selection of an antipsychotic agent be
guided by
◦ the patient's past medication history
◦ current symptoms
◦ co-occurring conditions
◦ other concurrent treatments, and preferences.
second-generation agents should be considered first-line options for
patients in the acute phase, mainly because of the decreased risk of
extrapyramidal side effects and tardive dyskinesia,
08/27/2024

08/27/2024 40
Dopamine
Dopaminergic
Neurons
'Negative' and positive signs
Serotonin
Serotonergic neurons
Decreased
dopaminergic
transmission
in
mesocortical
pathway
Frontal
cortex
Limbic
system
Normal
dopaminergic
transmission in
nigrostriatal
pathway
Increased
dopaminergic
transmission in
mesolimbic
pathway
Raphe
nuclei
VTA
S.nigra
Serotonin secreted by
neurons causes 5-HT2
receptor stimulation
and subsequent
inhibition of
mesocortical
dopaminergic
neurons
Intact
extrapyrami
al system
'Negative' signs
Positive
'signs

08/27/2024 41
Typical
Antipsychotics
Worsening
in 'negative'
signs
EPS
Improved 'positive' signs
Worsening of
negative symptoms
due to blockade of
the already
decreased
dopaminergic
transmission
in the mesocortical
pathway

08/27/2024 42
Atypical
antipsychotic
drugs
Infrequent extrapyramida
side-effects
Potential improvement
in 'negative' signs
Improved 'positive' signs
Improvement
in 'negative' signs due
to the much- increased
dopaminergic
transmission in
mesocortical pathway)
5-HT2 receptor
blockade
(by SGAs) stops the
inhibitory
effect of the
serotonergic neurons
on mesocortical and
nigrostriatal
dopaminergic neurons
(i.e. with subsequent
increase in their firing
rate)
Increased dopaminergic
firing rate in
mesocortical
and nigrostriatal
pathways overrides the
blockade by atypical
APDs
block postsynaptic D2 dopaminerg
receptors

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Schizophreniform disorder
Definition
 DSM-V-TR describes schizophreniform
disorder as similar to schizophrenia, except that
its symptoms last at least 1 month but less than
6 months.
 Patients with schizophreniform disorder return
to their baseline level of functioning once the
disorder has resolved
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08/27/2024 44
Cont………..
Epidemiology
 The disorder is most common in
adolescents and young adults and is less
than half as common as schizophrenia.
 A lifetime prevalence rate of 0.2 percent
and a 1-year prevalence rate of 0.1 percent
have been reported.

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Cont………………
Diagnosis and clinical features
 Schizophreniform disorder is an acute
psychotic disorder that has a rapid onset
 No progressive decline in social and
occupational functioning.
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Cont………..
 The initial symptom profile is the same as
that of schizophrenia in that two or more
psychotic symptoms (hallucinations,
delusions, disorganized speech and
behavior, or negative symptoms) must
be present.
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Cont……………….
 negative symptoms are relatively uncommon in
schizophreniform disorder and are considered
poor prognostic features.
 By definition, patients with schizophreniform
disorder return to their baseline state within 6
months.
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Cont………
Differential Diagnosis
 Secondary Psychosis ( detailed history and
physical examination and, when indicated,
performing laboratory tests or imaging
studies)..
 Other psychotic syndromes
 Mood disorders with psychotic features.
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Cont…………
Course and Prognosis
Most estimates of progression to schizophrenia
range between 60 and 80 percent.
What happens to the other 20 to 40 percent is
currently not known.
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Treatment
.
 Hospitalization.
 a 3- to 6-month course of antipsychotic drugs
(e.g., risperidone).
 Several studies have shown that patients with
schizophreniform disorder respond to
antipsychotic treatment much more rapidly than
patients with schizophrenia
 Psychotherapy
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Delusional Disorder
 Delusional disorder refers to a group of disorders, the chief
feature of which is the presence of non bizarre delusion
 People suffering from this illness generally do not regard
themselves as mentally ill and actively oppose psychiatric
referral.
 Because they may
 experience little impairment,
 they generally remain outside hospital settings,
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Cont…………..
 They are more likely to have contacts with
professionals such as lawyers and other medical
specialists for health concerns.
 Nonbizarre delusions typically involve situations
or circumstances that can occur in real life (e.g.,
being followed, infected, or deceived by a
lover) and are believable.
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Cont……………………
DELUSIONAL DISORDER
A. Non bizarre delusions (i.e., involving situations that
occur in real life, such as being followed,
poisoned,infected, loved at a distance,) of at least 1
month’s duration.
B. Criterion A for schizophrenia has never been met.
Note: Tactile and olfactory hallucinations may be
present.
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Cont……………………
C.functioning is not markedly impaired and behavior is
not obviously odd or bizarre.
D. If mood episodes have occurred concurrently with
delusions, their total duration has been brief relative
to the duration of the delusional periods.
E. The disturbance is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication)
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Specify type (the following types are assigned based on
the predominant delusional theme):
Erotomanic type: delusions that another person, usually of
higher status, is in love with the individual
Grandiose type: delusions of inflated worth, power,
knowledge, identity, or special relationship to famous person
Jealous type: delusions that the individual’s sexual
partner is unfaithful
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Cont………………………..
 Persecutory type: delusions that the person (or
someone to whom the person is close) is being
malevolently treated in some way
 Somatic type: delusions that the person has some
physical defect or general medical condition
 Mixed type: delusions characteristic of more than one
of the above types but no one theme predominates
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course
 Delusional disorder does not lead to severe impairment or
change in personality,but Suicide has often been associated
with this disorder.
 In almost half of the cases, the delusion disappears at
follow-up
 the more acute and earlier the onset of the illness, the more
favorable the prognosis.
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TREATMENT
 Though generally considered resistant to
treatment and interventions, the management is
focused on managing the morbidity of the
disorder by reducing the impact of the delusion
on the individual’s (and family’s) life.
 An effective and therapeutic clinician patient
relationship is important but difficult to establish.
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59
Cont…………
Shared Psychotic Disorder
In this disorder, the transfer of delusions takes place
from one person to another.
 Both persons are closely associated for a long time and
typically live together in relative social isolation.
 In its more common form, the individual who first has he
delusion is often influential member of the close
relationship with another individual
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60
Cont……………
 The second individual is frequently less intelligent,
more gullible, more passive, or more lacking in
self-esteem than the primary case.
 If the two people involved are separated, the
second individual may leave from the delusion.
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61
Cont…………
 An important feature in the diagnosis is that the
person with shared psychotic disorder does not have
a pre-existing psychotic disorder.
 The delusions themselves are often not as bizarre as
those seen in individuals with schizophrenia.
 This condition is more common in people from low
socioeconomic and in women.
08/27/2024

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Course
 Though separation of the submissive person from the
dominant person should resolve the psychosis, this
probably occurs only in 10–40% of the cases.
 Malingering,
 factitious disorder
 psychotic disorder due to a general medical condition
 substance-Induced psychotic disorder .
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Cont……………..
TREATMENT
 The initial step in treatment is to separate the affected
person from the source of the delusions.
 Antipsychotic agents may be used if the symptoms have
not become less intensive in a week after separation.
 Psychotherapy with the non delusional members of the
individual’s family should be undertaken
.
08/27/2024

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Cont……
Brief Psychotic Disorder
DIAGNOSIS
Brief psychotic disorder is defined by DSM-V-TR as a
psychotic disorder that lasts more than 1 day and less
than a month.
Moreover, the disorder may develop in response to
severe psychosocial stressors or group of stressors.
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Cont……………………
BRIEF PSYCHOTIC DISORDER
A. Presence of one (or more) of the following symptoms:
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g. Frequent derailment or
incoherence)
(4) grossly disorganized or catatonic behavior
Note: Do not include a symptom if it is a culturally
sanctioned response pattern.
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66
Cont……………………………
B. Duration of an episode of the disturbance is at least
1 day but less than 1 month, with eventual full return
to premorbid level of functioning.
C. The disturbance is not better accounted for by a mood
disorder with psychotic features, schizoaffective disorder,
or schizophrenia and is not due to the direct physiological
effects of a substance
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Cont……………….
Specify if:
With marked stressor(s) (brief reactive psychosis): if
symptoms occur shortly after and apparently in response
to events that, singly or together, would be markedly
stressful to almost anyone in similar circumstances in the
person’s culture
Without marked stressor(s): if psychotic symptoms do
not occur shortly after, or are not apparently in response
to events that, singly or together, would be markedly
stressful to almost anyone in similar circumstances in the
person’s culture
With postpartum onset: if onset within 4 weeks
postpartum 08/27/2024

68
Cont…..
The DSM-V-TR diagnostic criteria specify the
presence of at least one clear psychotic symptom
lasting a minimum of 1 day to a maximum of 1
month.
Furthermore, DSM-V-TR allows the specification of
two additional features: the presence or the absence
of one or more marked stressors and a postpartum
onset.
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69
Cont……………
DSM-V-TR
Once the duration criteria are met, other
conditions such as etiological medical illnesses
and substance-induced psychosis need to be
excluded.
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70
Clinical features
08/27/2024
People suffering from this disorder usually present with
an acute onset,
manifest at least one major symptom of psychosis
Affective symptoms, confusion, and impaired
attention may be more common in brief psychotic
disorders than in chronic psychotic conditions.

71
Cont……
 The precipitating stressors most commonly
encountered are major life events that would cause
any person significant emotional turmoil.
 Such events include the death of a close family
member or severe accidents.
 Rarely, it could be accumulation of many smaller
stresses.
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Course
 Individuals with brief psychotic disorders generally have good
prognosis, and European studies indicate that 50–80% of all
individuals have no further major psychiatric problems.
 Occasionally, depressive Symptoms follow the resolution of the
psychosis.
 Suicide is a concern during both the psychotic phase and post
psychotic depressive phase.
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Prognosis
Indicators of good prognosis- are
 good premorbid adjustment
 severe precipitating stressors
 sudden onset of symptoms
 little affective blunting
 short duration of symptoms
 absence of family history of schizophrenia
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 Major psychotic conditions
 Psychotic disorder due to a general medical
condition,
 Substance-induced psychosis,
 factitious disorder with predominantly
psychological signs and symptoms, and
malingering.
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TREATMENT
 short-term hospitalization for a comprehensive
evaluation and safety.
 Antipsychotic drugs are often most useful
along with benzodiazepines.
 Long-term use of medication is often not
necessary and should be avoided
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76
Cont…………………………….
 If maintenance medications are necessary, the
diagnosis may need to be revised.
 the newer antipsychotic agents have a better
neurological side effect profile and would be
preferred over the typical agents.
Psychotherapy is necessary to help the person
reintegrate the experience of psychosis
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77
Postpartum Psychosis
 Postpartum psychosis ( puerperal psychosis) is
an example of psychotic disorder not otherwise
specified that occurs in women who have
recently delivered a baby;
 the syndrome is most often characterized by the
mother's depression, delusions, and thoughts of
harming either her infant or herself.
08/27/2024

08/27/2024 78
Psychotic Disorders
Schizo-
phrenia
Usually
insidious
Many Chronic >6 months
Delusional
disorder
Varies
(usually
insidious)
Delusions
only
Chronic >1 mo.
Brief
psychotic
disorder
Sudden Varies Limited <1 mo.
Onset Symptoms Course Duration

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