Psychotic disorders Part I_ecbaa3342ac48654944bdf0fee3604e3.pdf

Schizophrenia Dr. Shehab H. M. Hassaan MBBch, ECFMG, M.Sc., M.D. Psychiatry Assistant Professor of Psychiatry Sulaiman Alrajhi University  Etiology  Diagnosis  Differential diagnosis  Investigations  Prognosis  Management  Pharmacological  Non-pharmacological...

Schizophrenia Dr. Shehab H. M. Hassaan MBBch, ECFMG, M.Sc., M.D. Psychiatry Assistant Professor of Psychiatry Sulaiman Alrajhi University  Etiology  Diagnosis  Differential diagnosis  Investigations  Prognosis  Management  Pharmacological  Non-pharmacological  Definition: Schizophrenia is a chronic mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self and behavior. Common experiences include means all the include s fields related feelin to grenotions hearing voices and delusions. · espe Conic Detailea b useby. supon  Etiology Schizophrenia is a “conspiracy” among many genes and many environmental stressors to cause abnormal development of brain connections throughout life” it has many factors it's multifatorial they the risk  Genetic Factors  These genes include but not exclusive to these genes responsible for Dysbindin, Neuregulin, COMT, and DISC1. a....  Dysbindin is involved in the formation of synaptic structures and regulation of the activity of the vesicular transporter for glutamate  Neuregulin is involved in neuronal migration, genesis of glial cells, and subsequent myelination of neurons by glia  DISC1 (disrupted in schizophrenia 1) a disrupted gene linked to schizophrenia that makes a protein involved in neurogenesis, neuronal migration, and dendritic organization  Genetics and The heritability of schizophrenia  Family Studies  Other family members are at increased risk of schizophrenia - Eba i  Twin Studies  Risk of schizophrenia in monozygotic twins is 48%  Risk of schizophrenia drops to 17% for (dizygotic) twins  Adoption Studies  Risk of schizophrenia remains high in adopted children with a biological parent suffering from schizophrenia  the brain effected -o Etiology of schizophrenia: by a structural abnormalities Brain scans and post mortem examination of schizophrenic patients show:  Reduced cell volume in the basal ganglia, temporal lobe and the hippocampus. ↳  The cerebral ventricles are larger than normal = low cell volume.  A disorganization of cell structure in the hippocampus It is not certain whether these structural changes are causes or resulting conditions vied retas disorganiseds Liver organized > - Neurodevelopmental theory of schizophrenia  The neurodevelopmental hypothesis of schizophrenia proposes that an adverse event in utero disrupts normal brain development and creates a vulnerability of the brain that predisposes an already at-risk individual to develop the disorder in later life.  There is also evidence to suggest that adverse postnatal conditions may contribute to the manifestation of schizophrenia, such as low socioeconomic status, unfavorable conditions in the home and the use of drugs, such as marijuana.  violetxiso ↓ Dis  Individuals who have suffered obstetric complications are more than twice as likely to develop schizophrenia than individuals without such complications.  Diabetes of pregnancy  Low birth weight (less than 2000 g)  Emergency Caesarian section  Small head circumference at birth is also associated with a higher incidence of schizophrenia   Maternal viral infections during the first and second trimester of gestation.  Exposure of the central nervous system to infectious agents during the period from birth to 14 years of age can also alter brain development and lead to psychosis.  Altered maternal nutritional status is associated with an increased risk for schizophrenia in offspring.  Vitamin D deficiency (particularly during the third trimester) is associated with an increased risk of developing schizophrenia  Neurotransmitters these are imp be the these. drugs will work on Care Empowerment Education  Dopamine at key  The dopamine hypothesis Antipsychotics Blockade of postsynaptic D2 receptors Imaging studies ↑ do p & taken with papkitso a Levodopa, amphetamines > - Many Stimulant Increased striatal dopamine Aggravâtes schizophrenia or the dopamin synthesis and release produce psychosis de novo Increased dopamine levels Dopamine-receptor density Nucleus accumbens, caudate Increased in shizophrenics and putamen (postmortem studies)  Glutamate  Glutamate hypofunction hypothesis of schizophrenia and the positive symptoms Glutamate leads to cortical brainstem glutamate increase Dopamine in Glutamate is a brake mesolimbic pathway for Dopamine in mesolimbic pathway (A) The cortical brainstem glutamate projection communicates with the mesolimbic dopamine pathway in the ventral tegmental area (VTA) to regulate dopamine release in the nucleus accumbens. (B) If NMDA receptors on cortical GABA interneurons are hypoactive, then the cortical brainstem pathway to the VTA will be overactivated, leading to excessive release of glutamate in the VTA. This will lead to excessive stimulation of the mesolimbic dopamine pathway  Glutamate hypofunction hypothesis of schizophrenia and the negative symptoms Glutamate leads to decrease Dopamine in mesocortical Glutamate is accelerator pathway for Dopamine in mesocortical pathway (A) The cortical brainstem glutamate projection communicates with the mesocortical dopamine pathway in the ventral tegmental area (VTA) via pyramidal interneurons, thus regulating dopamine release in the prefrontal cortex. (B) If NMDA receptors on cortical GABA interneurons are hypoactive, this leads to inhibition of mesocortical dopamine neurons. This reduces dopamine release in the prefrontal cortex  Glutamate thalamo-cortical pathway Glutamate has Preventing too inhibitory effect much sensory Thalamus information on processing too much Glutamate Over activity of sensory hypofunction the Thalamus information processing  The serotonin hypothesis 5-HT2C inverse agonists 5 Clozapine, asenapine, olanzapine Stability of 5-HT2A and NMDA receptors complex 4 Hallucinogens can modulate this stability. 5-HT2A receptors 3 Modulate the release of dopamine, norepinephrine, glutamate, GABA and acetylcholine. 5-HT2A inverse agonists and antagonists 2 Atypical antipsychotic drugs 5-HT2A and 5-HT2C stimulation 1 Basis of the hallucinatory effects of LSD and mescaline. Katzung, Masters, Trevor. Basic and clinical pharmacology. Psychosocial factors ↑ oral values is i s Freud very harsh childhood 1. Conflict model: experiences result in Due to this the person inner turmoil in the ceases to operate on patient giving rise to a conflict between the id, the basis of the reality ego and superego principle (tripartite apparatus). In particular, schizophrenia is it leads to fixation or linked to an early part of the oral stage called primary narcissism regression to early stages during which the ego had not of psychosexual development. separated from the id.  2. Deficits model: It is the ego’s job to keep control of the id’s impulses views and strike a compromise schizophrenia as between the id and the the result of the superego. deficits and disintegration of the ego. He maintained that a a weak and fragile ego can delusion is like a patch be ‘broken apart’ by its applied over the tear attempt to contain the id, between the ego and leaving the id in overall external world. control of the psyche. They regress to a state of ‘primary So, the person loses contact with narcissism’ incapable of organizing reality as they can no longer their own behavior and hallucinating distinguish between themselves and as a result of their basic inability to others, their desires and fantasies distinguish between their and reality (which is one of the imaginations and reality many functions of the ego). Federn: Ego boundaries psychology Each person has two ego boundaries: a. An outer ego boundary: which makes possible to distinguish between mental phenomenoa and real phenomena  Attenuation results in loss of distinction between what is in the mental space and real phenomena (e.g. hallucinations) b. An inner ego boundary: which consists a barrier between conscious and unconscious  Attenuation results in de-repression or re-emergence of the archaic ego states (regression in thinking and behavior)  Family Dynamics Gigi g i /c isk factor 5 50 , Double Bind.  The family in which children receive conflicting parental messages about their behavior, attitudes, and feelings. children withdraw into a psychotic state to escape the unsolvable confusion of the double bind. Schisms and Skewed Families.  In one family type, with a prominent schism between the parents, one parent is overly close to a child of the opposite gender. · and j widei  In the other family type, a skewed relationship between a child and one parent involves a power struggle between the parents and the resulting dominance of one parent.  Expressed Emotion. High EE is a family communication style that involves:  Critical comments through both tone and content, occasionally - ismin jig - - - - accompanied by violence  Hostility towards the patient, including anger and rejection  Emotional over-involvement in the life of the patient, including needless self-sacrifice S > - Migh · Higle di% - & jiGa  Many studies have indicated that in families with high levels of expressed emotion, the relapse rate for schizophrenia is high.  Diagnosis Of schizophrenia  DSM-V Diagnostic criteria 1. Two or more of the following for at least a one-month (or longer) period of time, and at least one of them must be 1, 2, or 3: 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms, such as diminished emotional expression 2. Impairment in one of the major areas of 3. Continuous signs of the disturbance persist functioning: Work, interpersonal relations, or self- for a period of at least 6 months, which care. must include at least 1 month of symptoms (or less if successfully treated). 4. Schizoaffective disorder and bipolar or depressive disorder with psychotic features have been ruled out 5. The disturbance is not caused by the effects of a substance or another medical condition  Symptom dimensions in schizophrenia Source: Schizophrenia Society of Canada. www.schizophrenia.ca/  Understanding the Symptoms of Schizophrenia Positive Symptoms Negative Symptoms Symptoms that are present in the Symptoms that involve a loss of person with schizophrenia that normal emotional responses or of were not seen when the person was other thought processes, e.g.: 5As healthy  Alogia –restrictions in the fluency and productivity of thought and speech  Delusions  Affective blunting or flattening – restrictions in  Hallucinations the range and intensity of emotional expression  Disorganized speech  Asociality – reduced social drive and interaction  Anhedonia – reduced ability to experience  Disorganized behavior pleasure  Catatonic behavior · &br ! 0 nds  Avolition – reduced desire, motivation or g Si persistence; restrictions in the initiation of goal- directed behavior  Cognitive symptoms of schizophrenia  Problems planning and decision making  Problems focusing and sustaining attention  Problems modulating behavior based upon social cues (ToM)  Impaired verbal fluency  Difficulty with problem solving  disorganized and slow thinking  difficulty understanding  Poor concentration  Poor memory  Difficulty expressing thoughts  Difficulty integrating thoughts, feelings and behavior Loss of in responses in... * ·jo. is  Schizophrenia subtypes have been eliminated: Perhaps the most substantial change to this category of disorders is the elimination of subtypes (paranoid, disorganized, catatonic, undifferentiated, and residual). The rationale for doing away with these subtypes is they are not stable conditions, and have not afforded significant clinical utility nor scientific validity and reliability.  Schizophrenia is Not the Same for Everyone Every person is affected differently  Different symptoms  Different severity  Different responses to different treatments  Different timing of symptoms (problems coming and going at different intervals)  lack of self Neige Case 1. A 35-year-old woman has lived in a state psychiatric hospital for the past 10 years. She looks disheveled with evidence of urine on her clothes. She spends most of her day rocking, muttering softly to herself, or looking at her reflection in a small mirror. She needs help with dressing and showering, and she often giggles, laughs or grimaces for no apparent reason. Some times she gets naked in front of the nursing staff while having a silly smile on her face. Case 2. A 36-year-old woman is brought to the psychiatrist by her husband because for the past 8 months she has refused to go out of the house, believing that the neighbors are trying to harm her. She is afraid that if they see her they will hurt her, and she finds many small bits of evidence to support this. This evidence includes the neighbors’ leaving their garbage cans out on the street to try to trip her, parking their cars in their driveways so they can hide behind them and spy on her, and walking by her house to try to get a look into where she is hiding. She states that her mood is fine and would be “better if they would leave me alone.” She denies hearing the neighbors or anyone else talk to her, but is sure that they are out to “cause her death”. Apart from this she is having a normal life.