Schizophrenia Spectrum Disorders PHA 535

• There are 164 slides in the overview.
• Log onto Socrative.com, Classroom: DEMSHOK for attendance.
• The course covers Schizophrenia Spectrum and Psychotic Disorders.
• The course is Human Behavior and Psychiatry PHA 535 for Spring 2025 by Professor Demshok.

Instructional Objectives

• Define psychotic and identify key diagnostic psychotic symptoms like delusions, hallucinations, and disorganized thought patterns.
• Evaluate presenting symptomatology, typical course, and treatment of schizophrenia using DSM-5-TR diagnostic criteria.
• These features include: delusions (and their types), ideas of reference, hallucinations, loose associations, blocking, neologisms, echolalia, echopraxia, thought insertion, thought broadcasting, blunted/flat affect, catatonia, and word salad.
• Distinguish between positive and negative symptoms of schizophrenia.
• Differentiate among prodromal, active, and residual phases of the disorder for treatment planning.
• Explain the role of neurotransmitters, particularly dopamine, in schizophrenia etiology and treatment.
• Identify psychotic disorders that can arise secondary to medical conditions or substance use, and diagnose them using clinical assessments.
• Apply DSM-5-TR diagnostic criteria to diagnose psychotic disorders including delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, and schizoaffective disorder.
• Prescribe antipsychotic medications by analyzing their side effect profiles, mechanisms of action (MOA), and appropriate follow-up protocols.
• Educate patients on treatment options and schizophrenia prognosis to enhance understanding and compliance with care plans.

Delusions vs Ideas of Reference

• Delusions have certainty whereby the person is convinced the delusion is real.
• Delusions are fixed, therefore the person cannot be convinced otherwise or have the belief shaken in any way.
• Delusions may be bizarre and an impossibility.
• Ideas of Reference feature incorrect interpretations of casual incidents and external events as having a particular and unusual meaning specifically for the person, and also magical thinking.
• Ideas of Reference can be changed.

Delusion

• A fixed false belief (excluding beliefs that are part of a religious movement).
• Cannot be convinced otherwise.
• Bizarre: impossible.
• Non-bizarre: possible, but no evidence to support.
• Somatic/Religious example: "I stubbed my toe because God punished me for an 'impure' thought."
• Referential example: "It rained because I thought it.”

Other Types of delusional disorders

• Erotomanic example: "That public figure is in love with me!"
• Grandiose example: "I'm the real celebrity. That's an imposter! I will single handedly keeping the PA Program going."
• Jealous example: "My partner is cheating and I will find proof!"
• Persecutory example: "Someone is trying to harm me. I have to stop them!"
• Somatic example: I have an infestation of parasites that are eating my liver up.
• Mixed: Characteristics of several of these.
• Unspecified: Other type of delusion "Doppelgänger".

Delusional Disorder

• Diagnostic criteria include one or more delusions (situations that can occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month
• Criterion A for Schizophrenia has never been met.
• Hallucinations, if present, are not prominent and are related to the delusional theme such as the sensation of being infested with insects associated with delusions of infestation.
• Functioning is not impaired, and behavior is not obviously odd or bizarre.
• Cognitive organization and reality testing are otherwise intact in delusional disorder.
• With bizarre content: clearly implausible, not understandable, and not derived from ordinary life experiences
• Examples:
• "(media outlet) took out my lung and sold it to support their work." (without leaving any wounds or scars.)
• “UFOs are causing the fires in California.”

Delusional Disorder Treatment

• Psychotherapy
• CBT
• 2nd generation anti-psychotics: risperidone or aripiprazole
• A characteristic of a delusion is not that corrects with evidence.

Psychosis

• A mental state involving a "break with reality" or "loss of contact with reality".
• Inability to recognize reality, communicate, and relate to others.
• Symptom, not an official DSM 5 TR diagnosis.
• Caused by a variety of conditions that affect the functioning of the brain.
• Includes hallucinations, delusions, thought disorders, and cognitive abilities
• Disorganized Behavior includes inappropriate social behaviors and unprovoked outbursts of hyperactive, agitated, or violent behavior.
• Severe neglect of hygiene or "bizarreness” of choice in clothing and general appearance.
• Presents with peculiar motor disturbances/repetitive gestures, rigid postures, overt signs of tension, and inappropriate laughing, grins or giggles.
• Please review Thought and Speech Patterns in Assessment Power Point.

Psychotic Characteristics

• Talking or mumbling to oneself.
• Glancing around as if hearing voices.
• Echopraxis: copying other people's movements, mannerisms, body language.
• Different than childhood imitation or mirroring
• Blocking: Interrupted speech or train of thought, only to be resumed later

Psychotic Thought/ Speech

• Blocking is usually related to thought withdrawal whereby thoughts are taken away by others or a force outside themselves.
• Thought insertion is a delusion in which the individual believes that thoughts have been irresistibly forced into their mind from an outside sources ("thought hallucination")
• Thought broadcasting is a person believing that their thoughts can be heard or known by people around them.
• Concrete speech: unable to think abstractly.
• Example: talking about "concrete thinking”, “It is raining cats and dogs."

Psychotic Hallucinations

• Definitions include Sensory perceptual distortions:
• Visual: seeing
• Auditory: hearing
• Olfactory: smelling
• Tactile: feeling
• Gustatory: tasting
• Sensations that others do not sense (usually) and do not exist outside one's perception, and not a seizure disorder.

Psychotic Characteristics

• Blunted/flat affect: Range of affective expression is markedly reduced, but not absent.
• Stupor: unresponsiveness.
• When used in the context of brain injury, this term implies unconsciousness, but with psychiatric conditions, awareness may be preserved
• Catatonia is a "motor dysregulation syndrome involving difficulty initiating or terminating actions"
• Catatonia can be Hyperkinetic/ hypokinetic.
• Catatonia has historically been associated with schizophrenia (35%), but catatonic symptoms are nonspecific and may occur in other mental disorders (e.g., bipolar or depressive disorders with catatonia) and in medical conditions (catatonic disorder due to another medical condition)
• The Pathophysiology of Catatonia is not completely known, but has genetics and Disruption of neurotransmission/ transmitters.
• This includes dopamine antagonists, Decreased GABA-A, and glutamatergic dysfunction
• Catatonia presents as Stuporous with a rigidly held posture, usually mute and unresponsive, waxy flexibility OR Driven, excited, excessive, but purposeless movements that are Involuntary
• To diagnose Catatonia requires at least 3 of the following:
• Stupor: no movement or response to stimuli
• Cataplexy: rigid body posture
• Mutism: little or no communication
• Waxy flexibility
• Negativism: lack of verbal response
• Grimacing
• Mannerisms: odd, circumstantial caricature of normal actions.
• Stereotypy: repetitive movements of any kind
• Agitation
• Echolalia
• Echopraxia
• Posturing: goes against gravity
• Medical complications of catatonia include aspiration, dehydration, nutritional deficiency, electrolyte abnormalities, weight loss, venous thromboembolism (ie, pulmonary emboli or deep vein thromboembolism), acute renal failure, muscle contractures, pressure ulcers, urinary tract infection, cardiac arrest and death.
• Catatonia requires immediate assessment to rule out medical causes such as encephalitis, nonconvulsive status epilepticus, Anti-NMDA receptor encephalitis, and is associated with 50% risk of death if untreated
• Catatonia Treatment includes admitting due to potential complications; treating with Benzodiazepine, as lorazepam (Ativan) is most commonly used; and If high doses of benzodiazepines are not effective within 48 to 72 hours, then electroconvulsive therapy (ECT).
• ECT should be considered sooner for patients with life-threatening catatonia or those who present with excited features or malignant catatonia, and response rates range from 80% to 100%.
• Repetition by a patient of another person's gestures is called Echopraxis.
• People with Psychosis feel special, but it's not right; people and things randomly become scary; and feel sort of special power or 6th sense that cannot control.
• They find it hard to trust the version of the world around them, see faces; hear voices and sometimes what sounds like a leaky pipe, and feel paranoid about the world around them, but don't want to be.
• Negative feelings can include being stuck at a carnival fun house when you don't know what is real and things are distorted; hearing everything around you all at once, and feeling terrifying, noisy, lonely and frustrating.
• They find themselves constantly arguing with yourself and looking around for the source of the voice you heard or the object that just flashed by-even if you're by yourself, where you not safe in your own house sometimes; feelings of betrayal with being confused and excited at the same time; and feelings of being frightened and confused and don't want to tell people what is going on because you can't think, or learn anything new because your brain stopped working and your feelings went away with no idea of what is real, or is that me.
• Types of Psychotic Disorders include Schizophrenia (most common), Schizoaffective Disorder, Schizophreniform Disorder, Delusional Disorder, Brief Psychotic Disorder, substance-induced Psychotic Disorder, Bipolar Disorder, Postpartum Psychosis / Pregnancy, Severe Depression, and Psychosis Suicide
• Depression and bipolar disorders do not need psychosis/psychotic features for a diagnosis
• Differential Diagnosis of Schizophrenia/ Psychotic Episode should test for: Tumor, Metabolic illness such as Wilson's Disease, porphyria, Endocrine disorders such as hypo/hyperthyroid, Cushing's, Addison's disease, Infectious disorders like HIV, syphilis, Lyme disease, mono, herpes, and Post partum psychosis.
• The testing should also assess: Genetic disorders like Tay- Sachs Disease, Autoimmune disorders like systemic lupus erythematosus (SLE), Neurologic disorders such as tumor, CVA, seizures, head trauma, MS, dementia, encephalopathy, for Vitamin deficiency of B 12, thiamine, niacin, Environmental toxins, and Medications such as anti- Parkinson and anti-malarial
• Workup of New-Onset Psychosis includes gathering a Detailed history and ROS; physical exam; and Labs/Diagnostic tests like Metabolic panel, CBC with diff, B12, Folate, RPR, VDRL, Serum Alcohol, Urinalysis, and Thyroid profile.
• Further testing should assess HIV Ab, ESR, Serum or CSF NMDAR IgG Abs, HIV serology, Lyme Disease and Epstein -Barr IgM, IgG titers, Urine drug screen.
• If indicated, CSF/LP, CT or MRI, and EEG should be administered
• The book narrates Susannah Calahan's anti-NMDA receptor encephalitis where NMDA Receptors are N-methyl-D-aspartate receptor which is a ligand of glutamate, the primary excitatory neurotransmitter in the human brain
• Psychosis can be a secondary characteristic, but not a diagnostic criteria in depression, mania and post partum psychosis.

Schizophrenia Facts

• Approximately 1 out of 100 Americans are schizophrenic.
• Schizophrenia is the 10th leading cause of disability world-wide.
• 26% of homeless have schizophrenia or bipolar disorder.
• Male/female ratio: 4:1.
• Schizophrenia is a brain disorder, poorly understood.
• Genetics, inflammation, faulty "circuits" and loss of compensatory circuits, enlarged ventricles, loss of grey matter, and ↑ dopamine receptors.
• Contributing Factors in Schizophrenia include, pregnancy complications, drug use (cocaine, marijuana, amphetamines, LSD) and stressors (bereavement, abuse, loss, low socio-economic class, limited social network).
• Certain behavioral indices such as switching topics abruptly or answering questions with irrelevant answers are indicative of Schizophrenia.
• In these patients later diagnosed with schizophrenia, fMRI showed ↑ activity superior temporal lobe gyrus (processing sounds) and limbic regions (emotion processing) connections.
• Prevention is possible using neurofeedback (?)
• Higher prevalence in children born in fall or winter (PANCE question?)?
• Early Detection of "Pre-Schizophrenia” can involve Portland Identification and Early Referral.
• Early intensive counseling and medication, preferably before hallucinations has been shown to decrease risk, severity and/ or recurrence
• Schizophrenia Treatment Barriers are lack of awareness, stigma, fear and delayed diagnosis.
• Schizophrenia: Shortened Life by 20–30 years shorter than the general population
• Between 25%-50% of patients attempt suicide, 10% eventually succeed.
• Mortality rate can be 8 X greater than the general population, where it is caused by premature cardiovascular disease; genetic and lifestyle factors; medications (including treatments); smoking, unhealthy diet; and lack of exercise leading to obesity and diabetes.

Schizophrenia Symptoms

• Positive (Added) Symptoms include delusions, hallucinations, distortions or exaggerations in language and communication, disorganized speech and behavior, catatonic behavior, and agitation.
• Negative Symptom Schizophrenia involves symptoms that are more difficult to treat and determine ultimate functioning in society.
• Negative symptoms are characterized by the five A's:
• Alogia: "poverty of speech"
• Anhedonia: no pleasure
• Asociality: no socializing
• Affective blunting: no expression
• Avolition: no motivation for action "Stinky"

Three Phases of Schizophrenia

• Prodromal
• Active
• Residual
• These phases occur in sequence and appear in cycles throughout the course of the illness.
• In the Schizophrenia Prodromal Phase, those affected begin to lose interest in their usual pursuits and withdraw from friends and family; are easily confused, have trouble concentrating, feel listless and apathetic, preferring to spend most of the time alone; intensely preoccupied with religion or philosophy; and family and friends may be upset with this behavior, believing the person is lazy rather than ill.
• Symptoms can reach a plateau and not develop further but, in most cases, an active phase follows, and can last weeks or months.

Other Information

• Serotonergic receptors: 5HT1A, 5HT2A, and 5HT2C.
• Glutamate is the principal CNS excitatory neurotransmitter.
• GABA (Gamma-Aminobutyric Acid) is the principal CNS inhibitory neurotransmitter (calming).

Brief Psychotic Disorder

• Diagnostic criteria for brief psychotic disorder include at least 1 of the following:
• Delusions (like Delusional Disorder except time limited)
• Hallucinations
• Disorganized speech (e.g., frequent derailment or incoherence)
• Grossly disorganized or catatonic behavior
• Duration: at least 1 day to 1 month, with eventual full return to premorbid level of functioning.
• The disturbance is not better accounted for by a Mood Disorder With Psychotic Features, Schizoaffective Disorder, or Schizophrenia
• Briefly psychotic disorder can be specified by the presentation by:
• With Marked Stressor(s) in response to event(s) that would be markedly stressful to almost anyone in a person's culture
• Without Marked Stressor(s)
• With Postpartum Onset: if onset within 4 weeks postpartum
• Includes HospitalizationMedical evaluation and laboratory testing
• Identify and eliminate or modify significant stressors.
• Administer Antipsychotic and benzodiazepine medication with an anticholinergic (diphenhydramine)
• To provide Brief Psychotic Treatment requires Long-term treatment
• Improving coping skills, establishing a network of social support, managing comorbid conditions such as personality disorders, reintegrating the patient into society while including education of their network
• Educating the patient to recognize early prodromal symptoms of impending psychosis, especially sleeplessness, facilitating sleep, nutrition, exercise, and hygiene, and avoiding alcohol or drug use.
• 50-80% have no further psychiatric illness
• Favorable Prognostic Indicators of Brief Psychotic Disorder can involve looking a a patient's Good premorbid adjustment, Few premorbid schizoid traits, Severe precipitating stressors, Sudden onset of symptoms, Affective symptoms, Confusion and perplexity during psychosis, Little affective blunting, Short duration of symptoms and Lack of schizophrenic relatives