COMMON FUNCTIONAL

PSYCHOTIC DISORDERS
1. SCHIZOPHRENI A

2. MANIA

3. DEPRESSION

4. BAD
SCHIZOPHRENIA

The word “schizophrenia," is derived from two Greek words:-

 Schizo- meaning split and
 Phren- meaning mind. So schizophrenia literally means a split mind.
Definition – schizophrenia is a major psychotic disorder often characterized by
disturbance in thinking, emotions, will power and other mental faculties all in
the presence of clear consciousness with the individual being out of touch
with reality.
There is a split in a patient thinks and what he/she speaks, a split in what
he/she feels and what he/she expresses.
Aetiology

The actual cause of schizophrenia is not known, however some factors are
thought to be contributing to the disease and include the following:-
 Genetic factors - studies show that children born to schizophrenic parents
have a high risk of suffering from schizophrenia and relatives of
schizophrenics have high risk of suffering from schizophrenia compared to
non schizophrenic parents and the general population. Monozygotic twins
have high risk as compared to dizygotic twins.
 Biochemical factors - (Neuro transmitter imbalances)
i- Dopamine- studies suggest that high levels of dopamine cause
schizophrenia.
Aetiology cont…

ii- Abnormalities in other neurotransmitters like serotonin, noradrenaline

acetylcholine, among others are thought to predispose an individual to
schizophrenia.
▪ Psychological factor- studies have shown that the relationship between
individuals in family set ups play a big role in the development of
schizophrenia.
i- studies show that a dysfunctional family where parents are very hostile to each
other, there is a high risk of having a schizophrenic daughter.
Ii- over protection of a child in early years of development was found out by early
theorists to have a contributing effect in development of schizophrenia. This
relationship with the child was observed to be so dominating and lead to retarded
ego development of the child.
Aetiology cont…

iii- In situations where parents convey two or more conflicting and

incompatible messages to a child at the same time was found to have a
great role in the development of schizophrenia. This is termed as double bind
communication.
▪ Social factors –
i- Individuals of very low social economic class and from areas of social
mobility and disorganization are thought are thought to be highly susceptible
to developing schizophrenia.
ii- A number of stressful life events are thought to precipitate schizophrenia in
already predisposed individuals such as wars, loss of loved ones, loss of job
among others.
Aetiology cont…

 Premorbid personality – studies reveal that people with schizoid personality

have high chances of developing schizophrenia.

SCHNEIDER’S FIRST – RANK SYMPTOMS OF SCHIZOPHRENIA

The presence of any of these symptoms is highly suggestive of schizophrenia.
i- Hallucinatory voices commanding in nature which the patient is compelled
to obey.
ii- Hallucinatory voices referring to the patient as a third person (third party
hallucinations).
Schneider’s symptoms cont…

iii- Thought alienation which may take the forms of thought withdrawal,
thought broad cast, thought insertion or thought echo (thoughts spoken
aloud).
iv- Running commentary- hearing voices commenting on every thing the
patient is doing.
V- somatic hallucinations- feeling insects crawling on or under their skin.
Vi- feelings , actions experienced as made or influenced by external agents.
Clinical features of schizophrenia

 In acute schizophrenia – patients will often present with:-

- Delusions
- Hallucinations
- Interference with thinking the predominant features are called positive
symptoms of schizophrenia or psychotic symptoms.
▪ In chronic schizophrenia – where patients do not completely recover from
the illness, they often present with the following features termed as
negative symptoms.
- Blunting of affect
- Apathy (lack of initiative)
Negative symptoms cont…

 Attentional impairment
 Anhedonia (inability to experience pleasure)
 A logia (lack of speech output)
 Social withdrawal.
TYPES OF SCHIZOPHRENIA
 Paranoid schizophrenia:- it’s one of the most common types of schizophrenia
characterized by – delusions of persecution
- Delusions of grandiosity
- Hallucinatory voices that commands or threatens the patient.
- Delusions of jealousy. –disturbance of affect, speech and behavior.
Types of schizophrenia cont…

NB. Paranoid schizophrenia has a good prognosis on condition that it is

treated early. Personality deterioration is minimal and most of the patients are
productive and can lead a normal life.
▪ Hebephrenic schizophrenia (disorganized schizophrenia):-
This type of schizophrenia has an early and insidious onset and is often
associated with poor premorbid personality.
Features include:-
- Hoarding rubbish
- Marked thought disorder, incoherence in speech, severe loosening of
associations and extreme social impairment.
Features cont…

 Delusions and hallucinations are fragmentary and changeable.

 Other odd behaviors include senseless giggling, mirror gazing, grimacing
and mannerisms.
NB. The course is poor and progresses down hill without significant remissions
and recovery classically never occurs and has the worst prognosis among all
the sub types.
▪ Catatonic schizophrenia:- this is a type of schizophrenia characterized by
marked disturbance of motor behavior. It always takes the form of
catatonic stupor, catatonic excitement and catatonia alternating
between stupor and excitement.
Features of catatonic excitement:-

 Increased psychomotor activity ranging from restlessness, agitation,

excitement, aggressiveness which may lead to violence.
 Accelerated speech with loosening of association and incoherence.
in severe excitement, schizophrenic patients are observed with rigidity,
hyperthermia and dehydration and can result into death, a condition known
as acute lethal catatonia or pernicious catatonia.
Features of catatonic stupor:-
▪ Mutism- generally meaning absence of speech.
▪ Maintenance of rigid posture despite any discomfort associated with the
posture.
Features cont…

 Negativism- doing the opposite

 Stupor – a patient does not react to his her surrounding and appears to be
unaware of it.
 Echolalia – repetition of phrases or words heard.
 Echopraxia – repetition of actions observed.
 Automatic obedience – obeys every command.
 Waxy flexibilitus – patient acquires an abnormal position for a long period
of time without feeling pain.
▪ Simple schizophrenia:-

This type of schizophrenia is characterized by early and insidious onset,

presence of a number of negative symptoms of schizophrenia, a progressive
course, wandering behavior, vague hypochondriacal features and is
characterized by a very poor prognosis.
Course and prognosis
Schizophrenia has been described as the most crippling and devastating of
all psychiatric illnesses. Several studies have found out that over 5-10 years
after the first psychiatric admission for schizophrenia, only about 10-20%can
be described as having a good outcome more than 50% of patients have
poor outcome with repeated hospitalization.
 Differential diagnosis

 Schizophreniform - has all the 1st rank symptoms of schizophrenia but lasts for at least 1
month but less than 6 months.
 Schizo affective – presence of either manic or depressive or mixed episode symptoms with
symptoms of schizophrenia. Delusions and hallucinations must have been persistent for at
least 2 weeks.

 Brief psychotic disorders – presence of one or more of the following:-

- Grossly disorganized or catatonic behavior.
- Hallucinations.
- Delusions.
- Disorganized speech .
- Duration at least one day but less than a month.
 Management of schizophrenia

 Chemotherapy – in acute schizophrenic episodes, classic antipsychotics provide an

immediate and quick relief of symptoms-
- chlorpromazine
- Haloperidol
- Tri fluperazine
- Risperidone
- Olanzapine
- Quetiapine
- Injection fluphenazine, Haldol decanoate and clopixol decanoate
Other forms of care

 Community visits.
 Regular follow ups to prevent relapses.
Preventive measures
▪ Identification of precipitating factors and educating on how to over come
them.
▪ Use of long term medications given on monthly basis.
MANIA

 Mania refers to a syndrome in which the central features are over activity,
mood change (which may be towards elation or irritability) and self
important ideas.
 The life time risk of manic episode is about 0.8-1%. This disorder occurs in
episodes lasting usually 3 to 4 months, followed by complete recovery.
Classification of mania
▪ Hypomania
▪ Mania without psychotic features
▪ Manic episode unspecified
 Clinical features

An acute manic episode is characterized by the following features which should last for at
least one week:-
 Elevated, expansive or irritable mood. Elevated mood in mania has 4 stages depending
on the severity of manic episodes.
- Euphoria – (stage 1):- increased sense of psychological well being and happiness not in
keeping with on going events.
- Elation – (stage 2):- moderate elevation mood with increased psychomotor activity.
- Exaltation (stage 3):- intense elevation of mood with delusions of grandeur.
- Ecstasy – (stage 4):- severe elevation of mood, intense sense of rapture.
Clinical features cont…

 Psychomotor activity – there is an increased psychomotor activity ranging

from over activeness and restlessness to manic excitement. The person
involves in ceaseless activity. These activities are goal oriented and based
on external environment cues.
 Speech and thought –
- Flight of ideas
- Pressure of speech
- Delusions of grandeur
- Delusions of persecution
- Distractibility
 Other features

 Increased sociability's
 Impulsive behavior
 Disinhibition
 Hypersexual and promiscuous behavior
 Poor judgement
 High risk activities(reckless driving, foolish business investments, distributing money to
unknown people).
 Over done fashions
 Decreased sleep and appetite
 Decreased attention and concentration
 Treatment

 Pharmacotherapy –
- Lithium carbonate 900-2100mg /day
- Carbamazepine 600-1800mg/day
- Sodium valproate 600-2600mg/day
- Other drugs-clonazepam, calcium channel blockers.
 Electro convulsive therapy – (ECT)
ECT can also be used to reduce interfamilial and interpersonal difficulties and to reduce or
modify stressors.
 Occupational therapy – give the patient some activities that needs mental concentration
so as to divert the excessive energy.
 Treatment cnt…

 Psychotherapy – the main purpose is to ensure continuity of treatment and adequate

drug compliance.
DEPRESSION
Depressive episode is a wide spread mental health problem affecting many people. The life
time risk of depression in males is 8-12% and in women 20-26%. Depression occurs twice as
frequent in women as in men.
Classification of depression
 Mild depression
 Moderate depression
 Severe depression
 Severe depression with psychotic features
Clinical features

The typical depressive episode is characterized by the following features,

which should last for at least 2 weeks in order to make a diagnosis.
 Depressed mood- sadness of mood or loss of interest and loss of pleasure in
almost all activities present throughout the day.
 Depressive cognitions – hopelessness, helplessness, worthlessness,
unreasonable guilt and self blame over trivial matters in the past.
 Suicidal thoughts – ideas of hopelessness are often accompanied by
thought that life is no longer worth a living and that death had come as a
welcome release. These gloomy preoccupation may progress to thoughts
of and for suicide.
 Clinical features cont…

 Psychomotor activity – psychomotor retardation is frequent. The retarded patient thinks,

talks, walks and acts slowly. Slowing of thoughts is reflected in the patients speech.
Questions are often answered after a delay and in a monotonous voice. In older patients
agitation is common with marked anxiety; restlessness and feeling of uneasiness.
 Psychotic features – some patients have delusions and hallucinations (the disorder may
then be termed as psychotic depression), these are often mood congruent, i.e. they are
related to depressive themes. E.g. Nihilistic delusions, delusions of guilt, delusions of
poverty may be present.
Clinical features cont…

 Significant decrease in appetite or weight

 Early morning awakening at least two or more hours before the usual time
of waking up.
 Diurnal variation with depression being to pleasurable stimuli
 Psychomotor agitation or retardation
 Difficulties in thinking and concentration.
 Menstrual or sexual disturbances.
 Vague physical symptoms such as fatigue aching, discomfort,
constipation.
 Treatment

 Pharmacotherapy - anti depressants are the drug of choice for vast majority of depressive
episodes.
 Electro convulsive therapy – (ECT) severe depression with suicidal risk is the most important
indication for ECT.
 Psychological treatment –
- Cognitive therapy- it aims at correcting the depressive negative symptoms like hopelessness,
worthlessness, helplessness and pessimistic ideas, replacing them with new cognitive and
behavioral responses.
- Supportive psychotherapy – various techniques are employed to support the patient these are
reassurance, ventilation, occupational therapy, relaxation.
Treatment cont…

 Group therapy – this is useful in mild cases of depression. In a group

therapy negative feelings such as anxiety, anger, guilt, despair, are
recognized and emotional growth is improved through expression of their
feelings.
 Family therapy is used to decrease familial and interpersonal difficulties
and to reduce or modify stressors which may help faster and more
complete recovery.
 Behavioral therapy – it includes social skills training, problem solving
techniques, assertiveness training , self control therapy, activity scheduling
and decision making techniques.
Course and prognosis

An average manic episode lasts for 3-4 months while a depressive episode
lasts 4-9 months.
Good prognostic factors
-Abrupt or acute onset
-Severe depression
-Typical clinical features
-Well adjusted premorbid personality
-Good response to treatment.
Poor prognostic factors

 Double depression
 Co morbid physical diseases, personality disorders or alcohol
dependence.
 Chronic ongoing stress poor drug compliance.
 Marked hypochondriacal features or mood incongruent psychotic
features.
THE END

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