SCHIZOPHRENIA

AND OTHER
PSYCHOTIC
DISORDERS

Teresita L. Martinez, M.D.
Teresita L. Martinez, MD, FPNA, FCNSP
SCHIZOPHRENIA AND OTHER PSYCHOTIC
DISORDERS

Historical Basis of the
disorder
Emil Kraepelin
Eugen Bleuler
Other Theorist
Epidemiology
Etiology
Stress Diathesis Model
Biological factors
Genetics
Psychosocial Factors

Diagnostic
Classification
Paranoid
Disorganized
Catatonic
Undifferentiated
Suicidal
Other Psychotic
Disorders
Schizophreniform
Schizoaffective
Delusional Disorder
Brief Psychotic Disorder
Teresita L. Martinez, MD, FPNA, FCNSP
SCHIZOPHRENIA
is a clinical syndrome of variable, but profoundly
disruptive, psychopathology that involves:
cognition
emotion
perception
usually begins before age 25
persists throughout life
affects persons of all social classes
Teresita L. Martinez, MD, FPNA, FCNSP
SCHIZOPHRENIA
EMIL KRAEPELIN

Dementia precox, a term that
emphasized the change in cognition
(dementia) and early onset (precox) of
the disorder.
Patients with dementia precox were
described as having a long-term
deteriorating course and the clinical
symptoms of hallucinations and
delusions.
Kraepelin distinguished these patients
from those who underwent distinct
episodes of illness alternating with
periods of normal functioning which he
classified as having manic-depressive
psychosis.
Teresita L. Martinez, MD, FPNA, FCNSP
SCHIZOPHRENIA
EUGENE BLEULER


coined the term schizophrenia
He chose the term to express the
presence of schisms between
thought, emotion, and behavior in
patients with the disorder.
schizophrenia need not have a
deteriorating course.
Teresita L. Martinez, MD, FPNA, FCNSP
THE FOUR AS

Bleuler identified specific fundamental (or primary)
symptoms of schizophrenia to
Associations
Affect
Autism
Ambivalence
Teresita L. Martinez, MD, FPNA, FCNSP
OTHER THEORISTS:
Ernst Kretschmer - compiled data to support the idea
that schizophrenia occurred more often among persons
with asthenic (i.e., slender, lightly muscled physiques),
athletic, or dysplastic body types rather than among
persons with pyknic (i.e., short, stocky physiques) body
types.
Kurt Schneider - description of first-rank symptoms and
second-rank symptoms
Karl Jaspers - existential psychoanalysis, trying to
understand the psychological meaning of schizophrenic
signs and symptoms such as delusions and
hallucinations.
Adolf Meyer - the founder of psychobiology, saw
schizophrenia as a reaction to life stresses


Teresita L. Martinez, MD, FPNA, FCNSP
KURT SCHNEIDER CRITERIA
FOR SCHIZOPHRENIA
First-rank symptoms
Audible thoughts
Voices arguing or discussing or both
Voices commenting
Somatic passivity experiences
Thought withdrawal and other experiences of influenced thought
Thought broadcasting
Delusional perceptions
All other experiences involving volition made affects, and made
impulses
Second-rank symptoms
Other disorders of perception
Sudden delusional ideas
Perplexity
Depressive and euphoric mood changes
Feelings of emotional impoverishment


Teresita L. Martinez, MD, FPNA, FCNSP
EPIDEMIOLOGY

In US -1 person in 100 will develop schizophrenia
during their lifetime
According to DSM-IV-TR, the annual incidence of
schizophrenia ranges from 0.5 to 5.0 per 10,000,
Schizophrenia is found in all societies and
geographical areas, and incidence and prevalence
rates are roughly equal worldwide.
Teresita L. Martinez, MD, FPNA, FCNSP
ETIOLOGY
DIATHESISSTRESS MODEL
is a psychological theory that explains behavior as
both a result of biological and genetic factors
("nature"), and life experiences ("nurture").
This model thus assumes that a disposition towards
a certain disorder may result from a combination of
one's genetics and early learning.
The term "diathesis" is used to refer to a genetic
predisposition toward an abnormal or diseased
condition.
Schizophrenia is produced by the interaction of a
vulnerable hereditary predisposition, with
precipitating events in the environment

Teresita L. Martinez, MD, FPNA, FCNSP
ETIOLOGY
GENETIC FACTORS

occur at an increased rate
among the biological
relatives of patients with
schizophrenia
likelihood of a person
having schizophrenia is
correlated with the
closeness of the relationship
to an affected relative
Population
Prevalence
(%)
General population 1
Non-twin sibling of a
schizophrenia patient
8
Child with one parent with
schizophrenia
12
Dizygotic twin of a
schizophrenia patient
12
Child of two parents with
schizophrenia
40
Monozygotic twin of a
schizophrenia patient
47
Teresita L. Martinez, MD, FPNA, FCNSP
ETIOLOGY
BIOCHEMICAL FACTORS

Dopamine Hypothesis
schizophrenia results from too much dopaminergic activity
Dopanine tracts responsible
Mesocortical - negative symptoms
Mesolimbic - positive symptoms
Nigrostriatal

Serotonin
serotonin excess as a cause of both positive and negative
symptoms in schizophrenia
Norepinephrine
selective neuronal degeneration within the norepinephrine reward
neural system could account anhedonia
The dopaminergic neurons in
these tracts project from their
cell bodies in the midbrain to
dopaminoceptive neurons in
the limbic system and the
cerebral cortex.
Teresita L. Martinez, MD, FPNA, FCNSP
ETIOLOGY
BIOCHEMICAL FACTORS

GABA
loss of GABAergic neurons in the hippocampus in patients with Schizophrenia
GABA has a regulatory effect on dopamine activity, and the loss of inhibitory
GABAergic neurons could lead to the hyperactivity of dopaminergic neurons
Neuropeptides
substance P and neurotensin -alteration in mechanisms could facilitate,
inhibit, or otherwise alter the pattern of firing these neuronal systems.
Glutamate
produces an acute syndrome similar to schizophrenia.
Acetylcholine and Nicotine.
decreased muscarinic and nicotinic receptors in the caudate-putamen,
hippocampus, and selected regions of the prefrontal cortex.
Teresita L. Martinez, MD, FPNA, FCNSP
ETIOLOGY
PSYCHOANALYTIC THEORIES
Sigmund Freud postulated that schizophrenia resulted
from developmental fixations that occurred earlier than
those culminating in the development of neuroses.
These fixations produce defects in ego development.
Ego disintegration in schizophrenia represents a return
to the time when the ego was not yet, or had just begun,
to be established.
Intrapsychic conflict arising from the early fixations and
the ego defect, which may have resulted from poor early
object relations, fuel the psychotic symptoms.
Psychoanalytic theory also postulates that the various
symptoms of schizophrenia have symbolic meaning for
individual patients
Teresita L. Martinez, MD, FPNA, FCNSP
ETIOLOGY
LEARNING THEORIES

Children who later have schizophrenia learn
irrational reactions and ways of thinking by
imitating parents who have their own significant
emotional problems.
In learning theory, the poor interpersonal
relationships of persons with schizophrenia develop
because of poor models for learning during
childhood.
Teresita L. Martinez, MD, FPNA, FCNSP
ETIOLOGY
FAMILY DYNAMICS
poor mother-child relationship had a sixfold
increase in the risk of developing schizophrenia,
and offspring from schizophrenic mothers who
were adopted away at birth were more likely to
develop the illness if they were reared in adverse
circumstances compared to those raised in loving
homes by stable adoptive parents
Teresita L. Martinez, MD, FPNA, FCNSP
ETIOLOGY
FAMILY DYNAMICS
Double Bind
The double-bind concept was formulated by Gregory Bateson
and Donald Jackson to describe a hypothetical 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
Theodore
schism - one parent is overly close to a child of the opposite gender
skewed - power struggle between the parents and the resulting
dominance of one parent.
Teresita L. Martinez, MD, FPNA, FCNSP
ETIOLOGY
FAMILY DYNAMICS
Pseudomutual and Pseudohostile Families
Lyman Wynne
some families suppress emotional expression by
consistently using pseudomutual or pseudohostile
verbal communication.
In such families, a unique verbal communication
develops, and when a child leaves home and must relate
to other persons, problems may arise.
Expressed Emotion
Parents or other caregivers may behave with overt
criticism, hostility, and overinvolvement toward a person
with schizophrenia.
Teresita L. Martinez, MD, FPNA, FCNSP
DSM-IV-TR DIAGNOSTIC CRITERIA
FOR SCHIZOPHRENIA

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):
1. delusions
2. hallucinations
3. disorganized speech
4. grossly disorganized or catatonic behavior
5. negative symptoms

B. Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice
keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing
with each other.
C. C. Social/occupational dysfunction:
D. Duration: 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
Teresita L. Martinez, MD, FPNA, FCNSP
DSM-IV-TR DIAGNOSTIC CRITERIA
FOR SCHIZOPHRENIA


E. Schizoaffective and mood disorder exclusion
F. Substance/general medical condition exclusion
G. Relationship to a pervasive developmental disorder:
If there is a history of autistic disorder or another pervasive
developmental disorder, the additional diagnosis of
schizophrenia is made only if prominent delusions or
hallucinations are also present for at least a month (or less if
successfully treated).
Teresita L. Martinez, MD, FPNA, FCNSP
DSM-IV-TR DIAGNOSTIC CRITERIA FOR
SCHIZOPHRENIA SUBTYPES

Paranoid type
Preoccupation with one or more delusions or
frequent auditory hallucinations.
Disorganized type
A type of schizophrenia in which the following
criteria are met: All of the following are
prominent:
disorganized speech
disorganized behavior
flat or inappropriate affect

Teresita L. Martinez, MD, FPNA, FCNSP
DSM-IV-TR DIAGNOSTIC CRITERIA
FOR SCHIZOPHRENIA SUBTYPES
Catatonic type
A type of schizophrenia in which the clinical
picture is dominated by at least two of the
following
motoric immobility as evidenced by catalepsy
excessive motor activity
extreme negativism or mutism
peculiarities of voluntary movement as evidenced by
posturing, stereotyped movements, prominent
mannerisms, or prominent grimacing
echolalia or echopraxia

Teresita L. Martinez, MD, FPNA, FCNSP
Undifferentiated type
A type of schizophrenia in which symptoms that meet
Criterion A are present, but the criteria are not met for
the paranoid, disorganized, or catatonic type.
Residual type
Absence of prominent delusions, hallucinations,
disorganized speech, and grossly disorganized or
catatonic behavior.
There is continuing evidence of the disturbance, as
indicated by the presence of negative symptoms or two
or more symptoms listed in Criterion A for
schizophrenia, present in an attenuated form

DSM-IV-TR DIAGNOSTIC CRITERIA
FOR SCHIZOPHRENIA SUBTYPES
Teresita L. Martinez, MD, FPNA, FCNSP
COURSE OF THE DISEASE
the symptoms begin in adolescence followed by the
development of prodromal symptoms
the prodromal syndrome may last a year or more
Exacerbations and remissions
After the first psychotic episode, a patient gradually
recovers and may then function relatively normally for a
long time.
Patients usually relapse
Further deterioration in the patient's baseline functioning
follows each relapse of the psychosis.
Sometimes, a clinically observable postpsychotic
depression follows a psychotic episode
Teresita L. Martinez, MD, FPNA, FCNSP
PROGNOSIS
Over 5-10 years, only 10-20% will have a good
outcome
More than 50 percent have poor outcome - with
repeated hospitalizations
Reported remission rates range from 10 to 60
percent, and a reasonable estimate is that 20 to 30
percent of all schizophrenia patients are able to
lead somewhat normal lives.
Teresita L. Martinez, MD, FPNA, FCNSP
TREATMENT
antipsychotic medications
psychosocial interventions- psychotherapy
Psychosocial modalities should be integrated into
the drug treatment regimen and should support it.
Teresita L. Martinez, MD, FPNA, FCNSP
PHASES OF TREATMENT IN
SCHIZOPHRENIA

lasts from 4 to 8 weeks
Hospitalization
Medications
Atypical
Typical
Teresita L. Martinez, MD, FPNA, FCNSP
PHASES OF STABILIZATION
AND MAINTENANCE PHASE
to prevent psychotic relapse and to assist patients
in improving their level of functioning
MEDICATIONS
Typical
Atypical
Depot preparations
Teresita L. Martinez, MD, FPNA, FCNSP
OTHER PSYCHOTIC
DISORDERS

Teresita L. Martinez, MD, FPNA, FCNSP
SCHIZOPHRENIFORM
Gabriel Langfeldt
1939
describe a condition with sudden onset and benign
course associated with mood symptoms and
clouding of consciousness.

Teresita L. Martinez, MD, FPNA, FCNSP
DSM-IV-TR DIAGNOSTIC CRITERIA
FOR SCHIZOPHRENIFORM
DISORDER
A. Criteria A, D, and E of schizophrenia are met.
B. An episode of the disorder (including prodromal, active, and residual
phases) lasts at least 1 month but less than 6 months. (When the
diagnosis must be made without waiting for recovery, it should be
qualified as provisional)
Specify if:
Without good prognostic features
With good prognostic features: as evidenced by two (or more) of the
following:
1. onset of prominent psychotic symptoms within 4 weeks of the first
noticeable change in usual behavior or functioning
2. confusion or perplexity at the height of the psychotic episode
3. good premorbid social and occupational functioning
4. absence of blunted or flat affect
Teresita L. Martinez, MD, FPNA, FCNSP
SCHIZOAFFECTIVE DISORDER

has features of both schizophrenia and affective disorders
In current diagnostic systems, patients can receive the
diagnosis of schizoaffective disorder if they fit into one of the
following six categories:
patients with schizophrenia who have mood symptoms
patients with mood disorder who have symptoms of schizophrenia
patients with both mood disorder and schizophrenia
patients with a third psychosis unrelated to schizophrenia and mood
disorder
patients whose disorder is on a continuum between schizophrenia
and mood disorder
patients with some combination of the above
Teresita L. Martinez, MD, FPNA, FCNSP
DSM-IV-TR DIAGNOSTIC CRITERIA
FOR SCHIZOAFFECTIVE DISORDER
A. An uninterrupted period of illness during which, at some time, there is
either a major depressive episode, a manic episode, or a mixed episode
concurrent with symptoms that meet Criterion A for schizophrenia.
Note: The major depressive episode must include Criterion A1: depressed
mood.
B. During the same period of illness, there have been delusions or
hallucinations for at least 2 weeks in the absence of prominent mood
symptoms.
C. Symptoms that meet criteria for a mood episode are present for a
substantial portion of the total duration of the active and residual periods
of the illness.
D. The disturbance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition.
Specify type:
Bipolar type: if the disturbance includes a manic or a mixed episode (or
a manic or a mixed episode and major depressive episodes)
Depressive type: if the disturbance only includes major depressive
episodes
Teresita L. Martinez, MD, FPNA, FCNSP
DELUSIONAL DISORDER AND SHARED
PSYCHOTIC DIS
Delusions are false fixed
beliefs not in keeping with
the culture
Delusions are Non bizarre

Nonbizarre means that the
delusions must be about
situations that can occur in
real life, such as being
followed, infected, loved at a
distance, and so on; that is,
they usually have to do with
phenomena that, although
not real, are nonetheless
possible
Advanced age

Sensory impairment or
isolation

Family history

Social isolation

Personality features (e.g.,
unusual interpersonal
sensitivity)

Recent immigration

Risk Factors:
Teresita L. Martinez, MD, FPNA, FCNSP
DSM-IV-TR DIAGNOSTIC
CRITERIA FOR DELUSIONAL
DISORDER
A. Nonbizarre delusions (i.e., involving situations that 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's duration.
B. Criterion A for schizophrenia has never been met.
Note: Tactile and olfactory hallucinations may be present in delusional disorder
if they are related to the delusional theme.
C. Apart from the impact of the delusion(s) or its ramifications,
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) or a general medical
condition.
Teresita L. Martinez, MD, FPNA, FCNSP
TYPES OF DELUSIONS
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 a deity or famous person
Jealous type: delusions that the individual's sexual partner is unfaithful

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

Unspecified type
Teresita L. Martinez, MD, FPNA, FCNSP
DSM-IV-TR DIAGNOSTIC
CRITERIA FOR SHARED
PSYCHOTIC DISORDER
A. A delusion develops in an individual in the context of a close
relationship with another person(s), who has an already-
established delusion.
B. The delusion is similar in content to that of the person who
already has the established delusion.
C. The disturbance is not better accounted for by another
psychotic disorder (e.g., schizophrenia) or a mood disorder
with psychotic features and is not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general

Teresita L. Martinez, MD, FPNA, FCNSP
BRIEF PSYCHOTIC DISORDER
psychotic condition that involves the sudden onset
of psychotic symptoms, which lasts 1 day or more
but less than 1 month.
Remission is full, and the individual returns to the
premorbid level of functioning.
Brief psychotic disorder is an acute and transient
psychotic syndrome
Teresita L. Martinez, MD, FPNA, FCNSP
DSM-IV-TR DIAGNOSTIC CRITERIA FOR
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
B. Note: Do not include a symptom if it is a culturally sanctioned response pattern.
C. 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.
D. 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 (e.g., a drug of abuse, a medication) or a general medical
condition.
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
Teresita L. Martinez, MD, FPNA, FCNSP
CULTURE-BOUND SYNDROMES
denotes specific arrays of behavioral and
experiential phenomena that tend to present
themselves preferentially in particular sociocultural
contexts and that are readily recognized as illness
behavior by most participants in that culture
Teresita L. Martinez, MD, FPNA, FCNSP
AMOK

A dissociative episode characterized by a period of
brooding followed by an outburst of violent,
aggressive, or homicidal behavior directed at
persons and objects.
The episode tends to be precipitated by a perceived
slight or insult and seems to be prevalent only
among men.
The episode is often accompanied by persecutory
idea; automatism, amnesia, exhaustion, and a return
to premorbid state following the episode.
Teresita L. Martinez, MD, FPNA, FCNSP
GHOST SICKNESS
A preoccupation with death and the deceased
(sometimes associated with witchcraft), frequently
observed among members of many American
Indian tribes.
Various symptoms can be attributed to ghost
sickness, including bad dreams, weakness, feeling of
danger, loss of appetite, fainting, dizziness, fear,
anxiety, hallucinations, loss of consciousness,
confusion, feelings of futility, and a sense of
suffocation.

Teresita L. Martinez, MD, FPNA, FCNSP
KORO
A term probably of Malaysian origin, that refers to
an episode of sudden and intense anxiety that the
penis (or, in women, the vulva and nipples) will
recede into the body and possibly cause death.
The syndrome is reported in South and East Asia,
where it is known by a variety of local terms, such as
shuk yang, shook yong, and suo yang (Chinese);
jinjinia bemar (Assam); or rok-joo (Thailand).
Teresita L. Martinez, MD, FPNA, FCNSP
PIBLOKTO
An abrupt dissociative episode accompanied by
extreme excitement of up to 30 minutes' duration
and frequently followed by convulsive seizures and
coma lasting up to 12 hours.
It is observed primarily in Arctic and subarctic
Eskimo communities, although regional variations
in name exist.
Teresita L. Martinez, MD, FPNA, FCNSP