MEDSURG_S2L5_SCHIZOPRENIA.docx.pdf

OT 10211 MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PSYCHOSOCIAL DYSFUNCTION SHIFT SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS Asst. Prof. Joselito B. Diaz, MD, FPNA, FPCPsych...

OT 10211 MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PSYCHOSOCIAL DYSFUNCTION SHIFT SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS Asst. Prof. Joselito B. Diaz, MD, FPNA, FPCPsych (03/01/2024) 02 LECTURE OUTLINE 1.2 HISTORY 1. Schizophrenia Spectrum Emil Kraepelin 1.1 Schizophrenia ○ Dementia precox 1.2 History Emphasizes the early onset and change in cognition in patients 1.3 Epidemiology with the disorder 1.4 Relative Prevalence of Schizophrenia to Medical Disorders Symptoms of hallucinations and delusions (important 1.5 Etiology: Genetic Factors 1.6 Etiology: Biochemical Factors symptoms) 1.7 Etiology: Neuropathology Long-term deteriorating course 1.8 Etiology: Neural Circuitry Coined the term dementia precox because it would be 1.9 Etiology: Psychosocial and Psychodynamic Theories presenting cognitive problems in young individuals. 1.5 Etiology: Genetic Factors Dementia and precox meaning early onset. 2. Diagnosis ○ Recognized this particular syndrome. 2.1 Schizophrenia Type 1 & 2 Eugene Bleuler 2.2 Clinical Course 2.3 Prognosis ○ Coined the term schizophrenia 2.3 Treatment Greek word meaning “split mind” 3. Schizotypal Personality Disorder Perceptions of individuals regarding schizophrenia, na may 3.1 Characteristics of Schizotypal Personality Disorder split personality. And that is not schizophrenia. That would 3.2 Subtopic be a dissociative disorder. Yung may multiple personalities. 3.3 Subtopic Schisms between thought, emotion and behavior in patients with 4. Other Psychotic Disorders the disorder in patients with schizophrenia 4.1 Schizophreniform Disorder 4.2 Brief psychotic Disorder Need not have a deteriorating course 4.3 Schizoaffective Disorder This term is what is used at the moment. 4.4 Delusional Disorder ○ Fundamental or primary symptoms: Four As Affect: inappropriate affect 1. SCHIZOPHRENIA SPECTRUM Ambivalence: indecision For DSM V, before, this would be classified as schizophrenia and other Associations: looseness of association disorders. Right now, they changed it to the schizophrenia spectrum. Autism: peculiar behavior Defined as abnormalities in one or more of the following domains: According to Bleuler, to diagnose schizophrenia, these are the 4 delusions, hallucinations, disorganized thinking (speech), grossly primary symptoms. disorganized or abnormal motor behavior, and negative symptoms ○ Accessory or secondary symptoms ○ Before this may only satisfy the definition of a psychiatric or a Hallucinations and delusions psychotic disorder. Includes schizophrenia and other psychotic disorders, and schizotypal (personality disorder) may be included in the schizophrenia spectrum. 1.3 EPIDEMIOLOGY If a person has a schizotypal type of personality, the likelihood that they Lifetime prevalence: 0.6-1.9% (approximately 1%) would be diagnosed later on with schizophrenia would be higher. ○ In the general population, the chance of developing schizophrenia is 1%. Or 1 out of 100. 1.1 SCHIZOPHRENIA Annual incidence: 0.5-5.0 per 10,000 persons ○ If you look at 10,000 individuals in a year, we would see around 0.5 A clinical syndrome of variable but profoundly disruptive to 5. psychopathology that involves problems with cognition, emotion, Often develops in early adulthood perception, and other aspects of behavior ○ 18-22 years in males; 24-30 years in women Clinical presentations, treatment responses, and courses of illness vary ○ Earlier onset in men. from one individual to another. Equal prevalence in men and women ○ It would be variable, so diagnosis and clinical presentations would ○ Women have a later onset, better premorbid functioning, less vary from one person to another. negative symptoms, better prognosis The problem with schizophrenia is that they would not only have a Better social support as well problem with their cognition, meaning that they may have intrusive Fertility rate is close to that of the general population thoughts, delusions, or false beliefs. They could also have emotional ○ That is the reason why this particular disorder could be perpetuating problems. kasi if you diagnose a person with schizophrenia, they are already Most patients with schizophrenia may also present with depression. Or, married or they already have children. at times, hypomanic or manic episodes. It could also include ○ The genetic load would be passed to the children, so the children hallucinations and delusions. are genetically vulnerable. Other behaviors would include catatonia, and others would have a Higher mortality rate from accidents and natural causes disorganized appearance. ○ Difficulty diagnosing and treating medical and surgical conditions Usually severe and chronic ○ 80% have significant concurrent medical illnesses, and ~50% may ○ Especially if they are not treated properly or if intervention is done be undiagnosed late. Natural causes because of their cognitive or psychotic Diagnosis based entirely on the psychiatric history and MSE symptoms, they do not realize that they have a medical ○ There is no particular biological marker for schizophrenia. problem. ○ There is no exam that would tell you that you would develop May highblood or diabetes na pala pero hindi dinadala sa schizophrenia later on in life. hospital. ○ If you are experiencing the signs and symptoms of schizophrenia, Sometimes, doctors are afraid to assess a person with there is no blood exam or neuroimaging that would tell you that you schizophrenia because they may be violent. Or the medical are schizophrenic. doctor may not be examining the patient closely. ○ It would be based mainly on your psychiatric evaluation. People with schizophrenia may be underdiagnosed. OT 10211 1  ○ Because of their cognitive problem, they would usually be the Reduces positive symptoms victims of hit-and-runs because they would cross the street all of a Reduces neuroleptic-induced parkinsonism sudden. Some of them are mga “taong grasa” or the people living in Decrease blood level of antipsychotics the streets. Nicotine-dependent activation of dopamine neurons ○ Increase dopamine 1.4 RELATIVE PREVALENCE OF SCHIZOPHRENIA TO MEDICAL Improves cognitive abilities DISORDERS It could be twice as common as Alzheimer’s Dementia. 1.5 ETIOLOGY: GENETIC FACTORS 5x more common than Multiple Sclerosis as well as type 1 Diabetes and Occur at an increased rate among biological relatives of patients with Muscular Dystrophy. schizophrenia This shows us that it is a common disorder. Individuals who are genetically vulnerable do not inevitably develop Research on the disorder is limited compared to Dementia and MS. schizophrenia If you look at the first world countries, this is the topmost topic of their ○ Environmental factors must be involved in determining research (dementia and MS), not schizophrenia because there is no schizophrenia outcome profit in studying schizophrenia. There may be genetic vulnerability but still environmental and Every year, there are new drugs available for dementia and MS, even psychological factors must be involved in the development and vaccines for dementia. But for schizophrenia, it is not a profitable outcome of schizophrenia. market. Paternal age >60 years ○ A risk factor is the father is >60 years old upon conception Genes linked to schizophrenia vulnerability (no need to memorize!) ○ 1q, 5q, 6p, 6q, 8p, 10p, 13q, 15q and 22q HERITABILITY OF SCHIZOPHRENIA The biological basis of schizophrenia is evident in heritability studies: Adoption studies ○ Schizophrenics adopted as children are likely to have schizophrenic biological relatives May schizophrenia ito, ito ay just an adopted child and if they look at their biological relatives makikita na there are family members who have the disorder. Ang significance nito ay ito ay iba na ang environment kasi yung pinaglakihan mo adopted na 1.3 EPIDEMIOLOGY (Cont.) child could develop schizophrenia later in life. There is no single gene that is identified in schizophrenia. In the northern hemisphere, persons with schizophrenia are more Twin studies often born in January to April (winter and early spring). ○ Concordance rates for schizophrenia are higher for identical than for In the southern hemisphere, often born in July to September fraternal twins: ○ Season-specific risk factors such as viral infection or seasonal No single gene identified for schizophrenia change in diet Seasonal change in diet would probably not be true now because we have refrigerators and food is available all throughout the year. ○ Influenza, rubella Could be because of viral infection, usually in the first and second trimester of pregnancy. Usually due to influenza or rubella. Causing a problem with brain development. The infant is vulnerable to developing schizophrenia later on. Kaya, that is the reason why they consider schizophrenia to be a neurodevelopmental disorder similar to autism and intellectual disability. More common in the urban areas of industrialized nations ○ They may have biological vulnerabilities, but it would be the psychosocial factors as well that would play a role in the PREVALENCE OF SCHIZOPHRENIA IN SPECIFIC POPULATIONS development of schizophrenia. Substance abuse is common POPULATION PREVALENCE (%) ○ Individuals with schizophrenia would also abuse drugs. General population 1 ○ Lifetime prevalence of drug abuse other than nicotine is >50% Non-twin sibling of a schizophrenic patient 8 Associated with poorer prognosis In our country, individuals with schizophrenia are also abusing Child with one parent with schizophrenia 12 methamphetamine or cannabis. The family would associate the Dizygotic twin of a schizophrenia patient 12 psychotic presentation of the client to the drugs when in reality, Child of two parents with schizophrenia 40 it would be because of the underlying schizophrenia. Patients are not treated properly because they would be placed Monozygotic twin / Identical twins of a schizophrenic 47 in a drug rehab facility. And in that facility, you are not given any patient medication. So in 6 months to 1 year that the client is there, they could also be deteriorating. Does this happen? The child of 2 patients who are schizophrenic usually Cigarette smoking meets in the psych facility. ○ Commonly used by patients with schizophrenia. If you go to a psych facility with patients that have schizophrenia, if you ask them what 1.6 ETIOLOGY: BIOCHEMICAL FACTORS they want as a gift or token, their answer would most likely be DOPAMINE HYPOTHESIS cigarettes. ○ ~90% dependent on nicotine Too much dopaminergic activity ○ Form of self-medication ○ In particular in the mesolimbic pathway OT 10211 2  ○ Efficacy of typical antipscychotic medications (act as antagonists of ○ Associated with prefrontal cortex the D2 receptors): dopamine receptor antagonists (DRAs) Basal ganglia and cerebellum If you give a medication that blocks the dopamine receptors ○ Control movement there is improvement ○ Movement problems ○ Drugs that increase dopaminergic activity (e.g., cocaine, ○ Patients present with odd movements (e.g., awkward gait, facial amphetamine) are psychotomimetic grimacing, stereotypies) If you give a drug that can cause secretion of too much Sometimes catatonia dopamine (e.g, cocaine, amphetamine) can cause the ○ Patients with movement disorders also present with psychosis development of psychosis Exemplified by Huntington’s chorea (Huntington’s disease – ○ Dopaminergic hyperactivity antisocial personality and later on hallucinations and delusions) Too much release of dopamine Patients with Parkinson’s – later on present with hallucinations Too many dopamine receptors ○ may be because of too much dopamine in the nigrostriatal pathway Hypersensitivity of the dopamine receptors ○ Increase D2 receptors in the striatum ○ 4 Dopaminergic pathways Prefrontal cortex Nigrostriatal pathway: extrapyramidal symptoms ○ Symptoms of schizophrenia mimics persons with prefrontal Dystonia, akathisia, parkinsonism, target dyskinesia lobotomies or frontal lobe syndromes Mesocortical pathway: negative symptoms Frontal lobe syndromes – may be secondary to tumor Secondary to hypodopaminergia Schizophrenia-like pathology Mesolimbic pathway: positive symptoms Thalamus E.g. hallucination and delusion brought about by ○ Reduction of neurons in the medial dorsal nucleus, which have hyperdopaminergia reciprocal connections with the prefrontal cortex Tuberoinfundibular pathway: hyperprolactinemia Midbrain That would cause: ○ Origin of dopaminergic, serotonergic and noradrenergic neurons Amenorrhea (women) Ventral tegmental area, substantia nigra, raphe nuclei, locus Galactosemia and Sexual dysfunction (Men and women) coeruleus because of too much prolactin Ventral tegmental area is the source of dopaminergic neurons Gynecomastia (Men) going to mesocortical to the mesolimbic pathway DOPAMINERGIC PATHWAYS ○ The side effects now of the intake of the antipsychotic medications is due to the nigrostriatal and the tuberoinfundibular pathways leading to the extrapyramidal syndrome (EPS) which includes Dystonia, akathisia, parkinsonism, target dyskinesia Limbic system, limbic lobe From the ventral tegmental area, dopaminergic neurons will project to the limbic lobe (mesolimbic pathway) – hippocampus SEROTONIN Serotonin excess as cause of both positive and negative symptoms of schizophrenia Effectiveness of atypical antipsychotics: Serotonin-dopamine antagonists (SDAs) ○ Evident by the effectiveness of the atypical antipsychotics ○ Which can both improve positive and negative symptoms Prefrontal cortex From the ventral tegmental area, going to the prefrontal cortex GABA (mesocortical pathway) Loss of GABAergic neurons in the hippocampus of some patients with If there would be reduction in dopamine in the mesocortical pathway – schizophrenia leads to negative symptoms ○ Hyperactivity of dopaminergic neurons Reduction in the amount of GABA GABA - inhibitory neurotransmitter ○ Loss – lead to hyperactivity of dopaminergic neurons 1.7 ETIOLOGY: NEUROPATHOLOGY AREAS OF INTEREST Limbic system ○ Seat of emotion ○ Decrease in size of the amygdala, hippocampus, parahippocampal gyrus ○ Disorganization of neurons in the hippocampus ○ Commonly seen is the atrophy of the hippocampus Basal ganglia OT 10211 3  Nigrostriatal pathway Developmental fixation produces defects in ego development ○ Principle guiding Id and Ego: reality principle CEREBRAL VENTRICLES ○ Id – pleasure Lateral and third ventricular enlargement and some reduction in ○ Ego – responsible for delaying gratification of the Id because it will cortical volume be taking into consideration the environment, then later on the CT and MRI development of the superego. ○ Some would show dilatation of the lateral and third ventricles Ego disintegration in schizophrenia represents a return to an earlier libidinal stage when the ego has not been established REDUCED SYMMETRY ○ Initially Id, then Ego, and then there could be stressful or traumatic Asymmetry in the frontal, temporal and occipital lobes events that can cause an Ego disintegration such that reality and Disruption in brain lateralization during neurodevelopment reality testing is impaired such that they would have hallucinations ○ May be secondary to this (above) and delusions. May be a neurodevelopmental disorder, such that during the Because hindi na nila alam what is real. development of the brain, the left or right side of the brain are not ○ Altered interpretation of reality and control of inner drives equally symmetrical Various symptoms of schizophrenia have symbolic meaning for individual patients ○ Nihilistic delusions, ideas of reference ○ How come an individual with schizophrenia will develop delusions of reference, for example? Feeling nila pinaguusapan sila, o pinagtatawanan sila ng ibang tao. ○ As a psychiatrist, you would like to determine the reason behind that particular delusion or hallucination. It can be that the individual have poor self-esteem, kaya naiisip nila na people don’t think of them as important enough that people are talking about them or behind their backs. Brain of 2 identical twins 2. DIAGNOSIS One would have schizophrenia DSM-5 Diagnostic Criteria for Schizophrenia ○ Lateral and the third ventricle are dilated A. Two (or more) of the following, each present for a significant portion ○ Cerebral cortex – reduction or smaller brain in schizophrenic of time during a 1-month period (or less if successfully treated). At least patients compared to the identical non-schizophrenic twin one of these must be (1), (2), or (3): ○ (1) delusions ○ (2) hallucinations 1.8 ETIOLOGY: NEURAL CIRCUITRY False beliefs that cannot be corrected by reasoning; “tamang Dorsolateral prefrontal circuitry/Mesocortical pathway hinala” ○ Negative symptoms of schizophrenia In schizophrenia, hallucinations are usually auditory. For some, Limbic loop pathway/mesolimbic pathway it may present as visual, gustatory, olfactory, or tactile. ○ Positive symptoms of schizophrenia ○ (3) disorganized speech (e.g., frequent derailment or incoherence) Commonly looseness of association (e.g., circumstantial, DORSOLATERAL PREFRONTAL LOOP PATHWAY tangential, neologism, etc.) or derailment We cannot understand their speech ○ (4) grossly disorganized or catatonic behavior Disorganization: does not take care of themselves, does not take a bath, does not change clothes, etc. May demonstrate catatonia or catatonic posturing ○ (5) negative symptoms, i.e., diminished emotional expression or avolition Flat or restricted affect Anhedonia: does not find pleasure in different activities Avolition: Low motivation to move or think Associality: withdrawn socially Alogia: doesn’t like to talk; speech is not spontaneous These are negative symptoms, the positive symptoms are the LIMBIC LOOP PATHWAY ones above (nos. 1-4). ○ Two out of five symptoms must be present in a significant portion for a period of 1 month. They are actively psychotic for at least 1 month. B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve the expected level of interpersonal, academic, or occupational functioning). ○ There would be social or occupational dysfunction. C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance 1.9 ETIOLOGY: PSYCHOSOCIAL AND PSYCHODYNAMIC THEORIES may be manifested by only negative symptoms or by two or more Individuals who are schizophrenic are usually fixated in the (oral, anal, symptoms listed in Criterion A present in an attenuated form (e.g., odd genital, latency) phase of the psychosexual development beliefs, unusual perceptual experiences). ○ Fixated in the oral stage – need for cigarette just to stimulate their ○ The duration of the illness should be at least 6 months, or 6 months mouth na mayroong siyang symptoms. OT 10211 4  ○ It would be required that in that 6 months, at least 1 month, they are 2.2 CLINICAL COURSE actively psychotic. Premorbid ○ We would also include the prodromal symptoms. ○ Prior to the index hospitalization (or acute psychotic episode), we D. Schizoaffective disorder and depressive or bipolar disorder with can already see premorbid symptoms. Those with these symptoms psychotic features have been ruled out because either (1) no major are the individuals prone to develop schizophrenia. depressive or manic episodes have occurred concurrently with the ○ Shy, quiet, passive, introvert active-phase symptoms; or (2) if mood episodes have occurred during ○ Few friends, exclusion of social activities active-phase symptoms, they have been present for a minority of the ○ Schizoid or schizotypal personalities total duration of the active and residual periods of the illness ○ If you are looking at the 6 months of illness, the premorbid may E. The disturbance is not attributable to the direct physiological effects already be included. of a substance (e.g., a drug of abuse, a medication) or another medical Prodrome condition. ○ Prior to the acute psychotic episode, this would be the one that F. If there is a history of autism spectrum disorder or a communication would fulfill the two out of five criteria. disorder of childhood onset, the additional diagnosis of schizophrenia is ○ Somatic symptoms (e.g., headache, fatigue) made only if prominent delusions or hallucinations, in addition to the ○ Attenuated behavioral changes and beginning social/occupational other required symptoms of schizophrenia, are also present for at least dysfunction a month (or less if successfully treated). ○ Interest in abstract ideas, philosophy, religion, and the occult What would be significant in the diagnostic criteria would be 2 of 5, and Example: All of sudden become hyper-religious, would believe one of the symptoms should be 1, 2, or 3; it should be present for at in clairvoyance and occult least 1 month, and the entire phase that the client is symptomatic should Acute index episode (~first hospitalization) be 6 months. Relapsing, remitting course! ○ We have to rule out other psychiatric disorders, medical disorders, ○ This is the course of schizophrenia. and physiological effects of the drug. NATURAL HISTORY OF SCHIZOPHRENIA 2.1 SCHIZOPHRENIA TYPE 1 & 2 TYPE 1 SCHIZOPHRENIA Active manifestations of abnormal behavior ○ E.g., delusions, hallucinations, the incongruity of affect, poor formal thought (disorganized speech and behavior). Distortions of normal behavior Includes delusions and hallucinations, incongruity of affect, and poor formal thought Good response to medication, optimistic prognosis, and absence of intellectual impairment Hyperdopaminergic activity in the mesolimbic pathway ○ If this would be the case, then typical antipsychotics are useful. Hence, they would have a better prognosis. Individuals with Type 1, may have an absence of intellectual impairment because dementia or cognitive decline is a common course of patients with schizophrenia. TYPE 2 SCHIZOPHRENIA The X axis shows the age, and the Y axis shows the level of functioning Individuals presenting with negative symptoms In the prodrome, you can see that there is already some attenuation or Absence or insufficiency of normal behavior deterioration in their level of functioning. Includes social withdrawal, flat affect, apathy, alogia, and anhedonia After prodrome would be the acute episode. It would be relapsing and Poor response to medication, pessimistic prognosis, and intellectual remitting. impairments After 5 to 10 years, it would plateau. But, they would not go back to their Hypodopaminergic activity in the mesocortical pathway normal level of functioning (compare the y-axis of blue to gray). There is Necessitate giving them atypical antipsychotic, they have a poorer a deterioration in the level of functioning as the disease progresses. prognosis and would develop intellectual impairment ○ Ang mahirap is when it occurs at an earlier time, especially among men. Makikita mo na they would start to have symptoms during or [VIDEO ON PATIENTS WITH SCHIZO] after college, especially those with a family history of schizophrenia. It would be difficult to explain to their parents why their child is In the video presented of patients with schizophrenia, they present with acutely psychotic. delusion, hallucinations, speech would be disorganized and there is a shift in the mood. CLINICAL COURSE (Cont.) You can see that most of them may have persecutory delusions, Classically, the course consists of exacerbations and remissions, though someone will kill him, suicidal ideations, they may commit suicide, have often not to “baseline” premorbid level of functioning mood disturbances ○ They do not go back to their baseline premorbid level of functioning. In patients with schizo, Suicide is usually secondary to command Illness progression often plateaus at 5 –10 years after initial diagnosis hallucinations (e.g., somebody or voices are telling them to suicide) Antipsychotic medications improve acute and long-term outcomes Second patient would have grandiose delusions that his thoughts are ○ Antipsychotic medications do help, especially if you start them early too smart and that they are being broadcasted in a university. There are on (early intervention). That would prevent deterioration in the level bizarre delusions. of functioning. In the female patient, you can see the mood lability. About 1/4 have a good outcome, 1/4 continue to have moderate Last patient, you can see the disorganized behavior. The picture showed symptoms, and 1/2 remain significantly impaired with current treatment; a headache, but he explained, “may sperm na may contact tas these numbers are changing with improved pharmacologic treatments nagkaroon ng protons” → this shows the looseness of association. and can be altered with therapy ○ Numbers are changing because of early intervention and the introduction of ATYPICAL ANTIPSYCHOTICS. OT 10211 5 2.3 PROGNOSIS Good Prognosis Poor Prognosis Late onset Young onset Obvious precipitating factors No precipitating factors Acute onset Insidious onset Good premorbid social, sexual, Poor premorbid social, and work histories sexual and work histories Mood disorder symptoms Withdrawn, autistic behavior (especially depressive Single, divorced, or widowed disorders) Family history of Married schizophrenia Family history of mood Poor support systems disorders Negative symptoms Positive symptoms History of perinatal trauma No remissions in 3 years Many relapses History of assaultiveness 2.4 TREATMENT ANTIPSYCHOTICS DRAs (typical) [dopamine-receptor antagonists] ○ Includes: Haloperidol, chlorpromazine ○ Can only treat positive symptoms and may worsen negative symptoms. ○ Looking at the potential side effects (refer to the picture below), these First Generation Antipsychotics have a high degree of ELECTROCONVULSIVE THERAPY (ECT) possibility of extrapyramidal symptoms. As effective as antipsychotic medications and more effective than SDAs (atypical) [serotonin-dopamine agonists] psychotherapy in acute schizophrenia ○ Some literature would say SGA or Second Generation ○ Walang indication for chronic schizophrenia but only here at the Antipsychotics. acute na phase merong role ang electroconvulsive therapy. The ○ Includes: Aripiprazole, risperidone, olanzapine, quetiapine, and same thing with your psycho surgery, wala rin siyang role sa chronic amisulpride schizophrenia. ○ Would target both positive and negative symptoms. ○ (Refer to picture below) Has a low degree of possibility of PSYCHOTHERAPY extrapyramidal symptoms. Psychotherapy would depend on what would be the target symptoms of ○ The problem with this is that it can cause metabolic syndrome your patient. Its side effect would be an increase in appetite or hyperphagia, causing patients to become obese. If they are obese, other 3. SCHIZOTYPAL PERSONALITY DISORDER secondary problems may arise, including diabetes, DSM-5 Diagnostic Criteria for Schizotypal Personality Disorder hypertension, and hyperlipidemia A. A pervasive pattern of social and interpersonal deficits marked by Given these considerations, you have to evaluate your client if you acute discomfort with, and reduced capacity for, close relationships as would give them typical or atypical antipsychotics. well as by cognitive or perceptual distortions and eccentricities of Looking at the natural course of schizophrenia, medication should be behavior, beginning by early adulthood and present in a variety of given for a lifetime. Once diagnosed, they should be given medication contexts, as indicated by five (or more) of the following: all throughout their lives. ○ Again, this is pervasive or persistent na change in their cognitive or What is the better medication? perceptual dysfunction, and eccentiricies ○ Atypical! ○ (1) Ideas of reference (excluding delusions of reference) ○ But the problem is the price. Here in the Philippines, medication is Delusion, by definition is a false belief that cannot be corrected out of pocket, unlike in industrialized countries, wherein it would be by listening. An ideas of reference would be a false of belief that subsidized by the government. In the PH yung branded, it would can be corrected by listening or magpakita ng proof na hindi cost 200 pesos or more but right now merong generics na atypical naman totoo, then mawawala. antipsychotic. But still, it would cost around 75-100 pesos a pill. Ideas of reference meaning everything that is happening Unlike your chlorpromazine that can be brought (inaudible) baka 5 aroundor something to do with me (ex. “Masyadong mainit pesos lang so ano ang bibigay mo? Kaya it depends. Sometimes ngayon kasi galit ang Diyos sa akin kaya gusto niya kong the family can initially sustain the patient but sometimes, may shift to pagpawiasan”, “nag uusap sila doon baka tungkol sa akin”) your atypical antipsychotic depending na lang talaga sa economics ○ (2) Odd beliefs or magical thinking that influences behavior and is ng family. inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations) they may be superstitious, yung mga telepathy, or sixth sense. There could be problem with their cognition ○ (3) Unusual perceptual experiences, including bodily illusions That would be now your perceptual distortion ○ (4) Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) That would be now your eccentricities of behavior Metaphorical, philosophical, and overelaborate speech or it may be vague ○ (5) Suspiciousness or paranoid ideations ○ (6) Inappropriate or constricted affect OT 10211 6  ○ (7) Behavior or appearance that is odd, eccentric, or peculiar Unlikely to have progressive decline in social and occupational ○ (8) Lack of close friends or confidants other than first-degree functioning relatives ○ Usually, return to baseline level of functioning state within 6 months ○ (9) Excessive social anxiety that does not diminish with familiarity Progression to schizophrenia range between 60- 80% later on and tends to be associated with paranoid fears rather than negative Treatment: antipsychotic medications judgments about self DSM-5 Diagnostic Criteria for Schizophreniform Disorder B. Does not occur exclusively during the course of schizophrenia, a A. Two (or more) of the following, each present for a significant portion bipolar disorder with psychotic features, another psychotic disorder, or of time during a 1-month period (or less if successfully treated). At autism spectrum disorder. least one of these must be (1), (2), or (3): ○ Note: If criteria are met prior to the onset of Schizophrenia, add ○ Similar to schizophrenia— Criterion A “premorbid," e.g., "Schizotypal Personality Disorder (Premorbid)." ○ (1) delusions ○ (2) hallucinations 3.1 CHARACTERISTICS OF SCHIZOTYPAL PERSONALITY DISORDER ○ (3) disorganized speech (e.g., frequent derailment or incoherence) Anxious in social relations and avoids people ○ (4) grossly disorganized or catatonic behavior “Different”, odd and nonconforming ○ (5) negative symptoms, (i.e., diminished emotional expression or Suspicious of others (e.g., ideas of reference) avolition) diagnosis Eccentricity of beliefs (such as in ESP or magic) B. An episode of the disorder lasts at least 1 month but less than 6 ○ Extrasensory perception / ESP months. When the diagnosis must be made without waiting for recovery, Unusualness of perceptions and experiences (e.g., illusions, it should be qualified as “provisional” derealization) ○ The only difference here is the duration of illness. Earlier, it was Disorganized thoughts and speech stated that schizophrenia should last until 6 months. But for the schizophrenic form, the symptoms are present for at least 1 to 6 months only. TYPICAL THOUGHTS OR BELIEFS ASSOCIATED WITH SCHIZOTYPAL ○ If you get that particular patient early on, around 60 to 80% of them PERSONALITIES would develop schizophrenia. Baka kasi maaga mo lang siyang “Relationships are always messy.” na evaluate. Kaya hindi niya pa nafu-fulfill ang 6 months. The “I manage best on my own and set my own standards.” reason behind less than 6 months but more than 1-month kaya “Intimate relationships are unimportant to me.” under siya ng schizophrenic form. “I hate being tied to other people.” Schizophrenic form usually has a good prognosis, and they ○ Because they prefer being by themselves. return to their baseline level of functioning within 6 months. “My privacy is more important to me than being close to others.” ○ If you think that this would be schizophrenia, but you have yet to “It’s best not to confide too much in others.” fulfill the 6 months criteria, it can be stated there that it is a ○ Again, meron silang paranoid ideations. schizophrenic form disorder (provisional). Because you are still awaiting whether they would be able to fulfill the criteria for schizophrenia, which is 6 months. C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition ○ Again, you have to rule out other psychiatric conditions such as drug abuse or another medical condition. What if the symptoms are less than 1 month? We call that a brief psychotic disorder. Again in schizophrenic form, it would be 1 month but less than 6 months. 3.2 BRIEF PSYCHOTIC DISORDER Psychotic condition that involves sudden onset of psychotic symptoms, which lasts 1 day or more but less than 1 month ○ Brief psychotic disorder would be a psychotic condition that involves sudden onset of psychotic symptoms, lasting for at least 1 day but There might be biological influences such as genetic vulnerability for less than a month schizophrenia Usually, this would be the cause of a brief psychotic disorder that is There could also be a preference for social isolation secondary to a stressful situation. Remission is full and returns to premorbid level of functioning 4. OTHER PSYCHOTIC DISORDERS Considered uncommon, seen more often in young adults, precipitated Schizophreniform disorder by major psychosocial stressors Brief psychotic disorder ○ Example: Doc Diaz has a patient who was seen last Saturday. He is Schizoaffective disorder 18 y.o currently living and studying Aeronautical Mechanics in Delusional disorder Bulacan. He is living alone in a dormitory in the province. Apparently, on Tuesday, he called crying because of his head 3.1 SCHIZOPHRENIFORM DISORDER hurting and stated that there was someone writing on his forehead Lifetime prevalence: 0.2% and he was already hearing voices. The mother was in denial and Annual prevalence: 0.1% stated that her son could still continue to study and go to school. Relatives of patients with schizophreniform disorder are more likely to Doc asked the parents to let the child rest first because of having have mood disorders auditory hallucinations and somebody writing information on his ○ Unlike patients with schizophrenia wherein the biological na relative forehead. Sudden onset. At the moment, it cannot really be usually also has schizophrenia determined what that particular stressor is. Because, according to Initial symptom profile similar to schizophrenia the patient or parent, there are no problems with school— no OT 10211 7  problems with classmates or any relationship for that matter. Though ○ During the duration of the illness, there’ll be a point in time wherein Doc already started him on medications and hopefully follow-up to they are only psychotic, so no mood symptoms, which should be at identify what could be the possible stressors of the patient. Usually, least 2 or more weeks. it could either be academics or relationships. C. Symptoms are met for a major mood episode are present for the DSM-5 Diagnostic Criteria for Brief Psychotic Disorder majority of the total duration of the active and residual portions of the A. Presence of one (or more) of the following symptoms. At least one illness of these must be (1), (2), or (3) D. The disturbance is not attributable to the effects of a substance (e.g., ○ (1) delusions a drug of abuse, a medication) or another medical condition ○ (2) hallucinations ○ Not secondary to a medical condition or an effect of a drug ○ (3) disorganized speech (e.g., frequent derailment or incoherence) ○ If you look at the diagnostic criteria for schizoaffective disorder, it’s ○ (4) grossly disorganized or catatonic behavior quite difficult to fulfill or interpret since may nakalagay na The difference between brief psychotic disorder, schizophrenia, and uninterrupted period of illness. Does an uninterrupted period of schizophrenic form illness mean 6 months or 1 year? Wala silang binigay. It just states ○ Brief psychotic disorder, only has 1 unless schizophrenia and that you should have hallucinations and delusions for at least 2 schizophrenic form which has 2 out of 5 symptoms. Here, we only weeks without any mood episodes. It is also mentioned that have 1 out of 4 symptoms. What is missing here is the negative “Symptoms are met for a major mood episode for the majority of the symptoms (i.e., diminished emotional expression or avolition) total duration of the illness.” Does majority mean 50%, 60%, or diagnosis. 70%? ○ If an individual is presenting negative symptoms for less than 1 ○ We are following the American Psychiatric Association, so they month, has a flat affect, social withdrawal, or does not like to recognized this particular disorder. In Europe, schizoaffective may converse with others, which is happening for less than a month. not be recognized as an illness. They only recognize it as either Then, what could be their medical diagnosis — depression with a mood or schizophrenia. brief psychotic disorder? Increasing presence of schizophrenic symptoms predicted worse ○ The duration should be at least 1 day but less than a month. prognosis ○ Note: Do not include a symptom if it is a culturally sanctioned Treatment: mood stabilizers, antipsychotic medications, antidepressants response pattern. (given with precaution), psychotherapy 📽️: B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with an eventual return to a premorbid level of functioning. VIDEO My Struggle with Schizoaffective Disorder C. The disturbance is not better explained by a major depressive or Here is a guy who has schizoaffective disorder, and he will tell you that bipolar disorder with psychotic features or another psychotic disorder his illness when was receiving only antipsychotic medication, is not such as schizophrenia or catatonia and is not attributable to the really improving. When he started taking mood stabilizers, physiological effects of a substance (e.g., a drug of abuse, a medication) improvements were noticed. or another medical condition. He felt like he had a very important message, a very important vision for ○ Again, you have to rule out other psychiatric conditions or another the world and for all human beings that he had to express. At various medical condition or effects of a substance. times, he was diagnosed with depression, bipolar disorder, and schizoaffective disorder. The medications he has taken were wellbutrin, 3.1 SCHIZOAFFECTIVE DISORDER lithium, lorazepam, clonazepam, risperidone, Cipralex, Celexa, Has features of both schizophrenia and mood disorders (mania or Seroquel, Paxil, Zoloft, valproic acid, lamotrigine, olanzapine, and depression) trazodone. ○ Either manic or depression Schizoaffective disorder is one notch below schizophrenia, where you May include patients in the following categories don’t see or actually hear anything, but you have these feelings that ○ Patients with schizophrenia who have mood symptoms aren’t necessarily real, where your friends or family hate you. There is ○ Patients with mood disorder who have symptoms of schizophrenia intense paranoia, fear of leaving the house, and extreme anxiety, which ○ Patients with both mood disorder and schizophrenia makes it painful for him to exist. ○ Patients with a third psychosis unrelated to schizophrenia and mood In Grade 10, he started feeling extreme sadness when nothing was disorder enjoyable for him. He couldn’t focus at school, didn’t like seeing his ○ Patients whose disorder is on continuum between schizophrenia friends, and didn’t find video games enjoyable. He saw a family doctor and mood disorder and started on Celexa (an antidepressant). He found out that Celexa ○ Patients with some combination of the above didn’t do anything, so he saw a couple of different psychiatrists. He was Lifetime prevalence: around 0.5-0.8% put on Paxil, but his behavior changed to being very distant and Two types: bipolar and depressive types disconnected. His family couldn't even talk to him anymore, and the only F>M thing he could really do was either end things or make a big statement ○ More common among female or impact to make people understand that this was a whole other level of Increased risk of schizophrenia among relatives of patients with pain going on, so he actually recorded him smashing ketchup and schizoaffective disorder barbecue sauce bottles with a bat at his basement, and he also hid ○ Imagine a spectrum. Depression or mood disorder and knives around his house. schizophrenia. In between them is schizoaffective disorder. Throughout this period, he went to the emergency room a couple of Hence, Better prognosis than patients with schizophrenia and worse times, now trying to commit suicide. The hospital wouldn’t take patients than patients with mood disorder in unless the police brought them in, so his parents’ only option was to ○ Since schizoaffective disorder is in between the two disorders. call the police and have him escorted over to the hospital. One day, he DSM-5 Diagnostic Criteria for Schizoaffective Disorder was in his bedroom. There was a knock at his door, and the police were A. An uninterrupted period of illness during which there is a major at his bedroom door. He was taken over to the hospital. As far as he mood episode (major depressive or manic) concurrent with Criterion A remembered, he didn’t want to go in, so he was in the hospital for about of schizophrenia a month. He was put on 4 medications right away, and he was thrown ○ Criterion A of schizophrenia would be 2 or more of the into this other world that was just a complete shock to the system where following, lasting for 1 month, and one of the symptoms should he really had to accept what was happening in order to start to get well; be (1), (2), or (3). There is also a mood episode. however, it took a long time to get to that acceptance. ○ Note: The major depressive episode must include Criterion A1: After the hospital, a very long depression, and there were really no Depressed mood improvements for virtually two years. The feelings were very much B. Delusions and hallucinations for 2 or more weeks in the absence of suicidal on a daily basis for him, and it was a matter of mentally figuring a major mood episode (depressive or manic) during the lifetime out how to keep any amount of hope at all. duration of the illness OT 10211 8  Cognitive Behavior Therapy was really the system that he really began ○ Usually seen in the elderly. Si lolo inaaway si lola dahil si lola ay using to figure out what was real in a sense and what wasn’t. It is nakiki-api sa kapitbahay. Every time na lalabas si lola, ang belief ni essentially writing down your thoughts on paper and analyzing them. lolo na nanglalaki na! Being able to do that really helped him look at things from a third ○ Most common in women but can be seen also in men especially perspective and separate himself from himself. there are some that have different roles in the family. Where man Doc’s Summary: stays at home and woman is the breadwinner ○ As mentioned, he was being treated with antidepressants pero wala ○ Example: Pinapaki-alaman ang cellphone ng asawa na kapag may masyadong improvements. He was then introduced to antipsychotic nagtext may ibang babae na medication (mood stabilizers) in the form of lithium. Nagkaroon Erotomanic type (de Clerambault syndrome) naman ng improvements pero may mga side effects lang talaga ang ○ Belief that somebody that is higher stature is inlove with them ating mga medications. Over some time, usually, this would happen Example: Doc’s patient, yung kapitbahay niya na lawyer ay may na baka pwede na idiscontinue ang gamot because of the side gusto sa kanya, kapag papasok sa gate ang sasakyan effects at ayaw mo na siya. In the case of the patient, nagkaroon ng nilalakasan daw para magising siya at para siya ay tingnan. recurrence of depression symptoms. She’s on horizontally challenge, her belief ay gusto siya kahit ○ Individuals with schizophrenia need to be medicated. wala naman siyang kahit anong contact with that person ○ Are there any alternatives? Somatic type Injectable medications. These are usually given monthly. ○ Belief na merong gumagapang-gapang sa kanilang balat However, if you are going to be giving the atypical ○ Makikita mo sila they are picking their skin kasi daw may uod sa antipsychotics that are injectable, it would cost around Php kanilang skin or nails 10,000 per injection (monthly), especially for the newer ○ Another is yung nagcocover ng panyo sa mouth kasi daw bad medication. Unfortunately, patients may have a hard time breath kahit wala purchasing these injections unless they are in the higher ranks ○ Doc’s pt, belief ng isang teacher na meron siyang body odor and of society. kahit anong gawin hindi matanggal, ang deodorant daw na would be ○ Since they have mood problems, another form of treatment that bought pa sa Saudi ang makakatulong. Pinagtatawanan daw siya would be very effective for patients with schizophrenia would really ng students niya kasi mabaho kahit hindi naman. be psychotherapy, as mentioned by the patient in the video. Aside Grandiose type from the drugs, you also need to have psychotherapy. ○ Before there is somebody who is running for president, his belief is that he owns the Philippines 3.1 DELUSIONAL DISORDER ○ During american’s idol, they believe na they are the best singers Patients exhibit non-bizarre delusions that cannot be attributed to other pero kapag kumanta naman ay talagang kapangit tapos psychiatric disorders mang-aaway pa kapag they are criticized because for them they are Nonbizarre delusions the best singer ○ Can occur in real life, although not real, are nonetheless possible Mixed type ○ Some patients also present with bizarre delusions. ○ Combination of the three Prevalence (in the US): 0.025-0.03% Unspecified type ○ Prevalence is a little bit lower. Annual incidence: 1-3 per 100,000 persons VIDEO 📽️: DELUSION OF INFIDELITY (aka mareshka) Mean age of onset: 40 years Jealous type F>M He believes that his wife is having an affair and he became suspicious