LECTURE Schizophrenia. Bipolar affective disorder Department of Psychiatry, Narcology, Medical Psychology and Social work. Schizophrenia a chronic mental disease with unclear etiology, which develops on the basis of hereditary predisposition and is characterized by autism, emotional flattening, reduced activity, loss of the integrity of mental processes with various productive psychopathological symptoms. σχίζω (schizo )– split φρήν (phren) – mind, soul History: Emil Wilhelm Magnus Georg Kraepelin (1894) united - dementia precox - hebephrenia - catatony - paranoid History: Eugen Bleuler (1911) proposed term “schizophenia” Age-related demographics: According to DSM5, the onset of schizophrenia usually occurs between the late teens and the mid 30s Sex-related demographics • The prevalence of schizophrenia is about the same in men & women • The onset is later in women than in men • The clinical course is less severe in women than in men Race-related demographics No racial differences in the prevalence of schizophrenia have been positively identified 1.Genetics, Family history, Brain chemical imbalance 2.Environmental factors 3.Social and Psychological factors RISK FACTORS: • Dopaminergic system hypothesis • Glutaminergic dysfunction • Serotonin abnormalities Increased Ventricular size Decreased brain volume in medial temporal areas Changes in the hippocampus ICD-10 classification • F2 Schizophrenia, schizotypal and delusional disorders. • F20 Schizophrenia • F21 Schizotypal disorder • F22 Persistent delusional disorders • F23 Acute and transient psychotic disorders • F24 Induced delusional disorder • F25 Schizoaffective disorders • F28 Other nonorganic psychotic disorders Schizophrenia • F20.0 Paranoid schizophrenia • F20.1 Hebephrenic schizophrenia • F20.2 Catatonic schizophrenia • F20.3 Undifferentiated schizophrenia • F20.4 Post-schizophrenic depression • F20.5 Residual schizophrenia • F20.6 Simple schizophrenia • F20.8 Other schizophrenia • F20.9 Schizophrenia, unspecified Clinical manifestations In general: fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. • • • • • • Hallucination Delusion Abnormal Behaviour Disorganised speech; incoherent or irrelevant speech Disturbances of emotions Symptoms typically come on gradually, begin in young adulthood, and last a long time. Main symptoms 4 “A”: • Ambivalence – severe inability to decide for or against • Autism – withdrowal into self • Affect disturbance • Association disturbance – loosening of associations, thoughts disorders SIMPTOMS OF SCHIZOPHRENIA: Positive symptoms Delusions Movement disorder Thought disorder Hallucination Negative symptoms Social withdrawal Hypo-/ Abulia "Flat affect," (monotonous speech and facial expression) Lack of self-care Low energy Anhedonia Cognitive symptoms Thinking Attention Memory IQ Paranoid Schizophrenia Hebephrenic Schizophrenia Catatonic Schizophrenia Simple Schizophrenia Paranoid schizophrenia is characterized mainly by delusions of persecution, feelings of passive or active control, feelings of intrusion, and often by megalomanic tendencies also. The delusions are not usually systemized too much, without tight logical connections and are often combined with hallucinations of different senses, mostly with hearing voices. Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous. Commonest type Hebephrenic schizophrenia is characterized by disorganized thinking with blunted and inappropriate emotions. It begins mostly in adolescent age, the behavior is often bizarre. There could appear mannerisms, grimacing, inappropriate laugh and joking, pseudophilosophical brooding and sudden impulsive reactions without external stimulation. There is a tendency to social isolation. Usually the prognosis is poor because of the rapid development of "negative" symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young adults. Denoted also as disorganized schizophrenia Catatonic schizophrenia is characterized mainly by motoric activity, which might be strongly increased (hypekinesis) or decreased (stupor), or automatic obedience and negativism. We recognize two forms: productive form — which shows catatonic excitement, extreme and often aggressive activity. Treatment by neuroleptics or by electroconvulsive therapy. stuporose form — characterized by general inhibition of patient’s behavior or at least by retardation and slowness, followed often by mutism, negativism, fexibilitas cerea or by stupor. The consciousness is not absent. Simple schizophrenia is characterized by early and slowly developing initial stage with growing social isolation, withdrawal, small activity, passivity, avolition and dependence on the others. The patients are indifferent, without any initiative and volition. There is not expressed the presence of hallucinations and delusions. Organic syndrome • • • • • Drug Temporal lobe epilepsy Delirium Dementia Diffuse brain disease Psychotic mood disorder Personality disorder Schizoaffective disorder The criteria should be the following features: • acute beginning (to two weeks) • presence of typical symptoms (quickly changing “symptoms”) • presence of typical schizophrenic symptoms. Complete recovery usually occurs within a few months, often within a few weeks or even days. Usually happens to Bipolar patients. The disorder may or may not be associated with acute stress, defined as usually stressful events preceding the onset by one to two weeks. 1. Mental status examination 2. Physical & neurological examination 3. Complete family & social history (take in consideration family history of response to drugs) 4. Psychiatric diagnostic interview 5. Laboratory work up ( CBC, electrolytes, hepatic & renal functions, ECG, FBG, lipid profile, thyroid functions and urine drug screening ) PPANSS: Pharmacological treatment Traditional antipsychotics • Particularly effective against positive symptoms • Significant improvement is seen in 70% of patients Pharmacological treatment Atypical antipsychotics • Useful against negative symptoms Social skill training Employment training Cognitive remediation therapy Psychoeducation Family therapy Psychotherapies Definition: BAD - a disorder characterized by two or more episodes in which the patient's mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression). Repeated episodes of hypomania or mania only are classified as bipolar. Types of Bipolar disorder: Bipolar I disorder Bipolar II disorder Cyclothymic disorder Substance/ medication-induced bipolar and related disorder Bipolar and related disorder due to another medical condition Other specified bipolar and related disorder F31 Bipolar affective disorder (ICD-10): • F31.0 Bipolar affective disorder, current episode hypomanic • F31.1 Bipolar affective disorder, current episode manic without psychotic symptoms • F31.2 Bipolar affective disorder, current episode manic with psychotic symptoms • F31.3 Bipolar affective disorder, current episode mild or moderate depression • F31.4 Bipolar affective disorder, current episode severe depression without psychotic symptoms • F31.5 Bipolar affective disorder, current episode severe depression with psychotic symptoms • F31.6 Bipolar affective disorder, current episode mixed • F31.7 Bipolar affective disorder, currently in remission • F31.8 Other bipolar affective disorders Manic episode: Period of an elevated, expansive or unusually irritable mood exists (at least one week). A person engaged in significant goal-directed activity beyond their normal activities. Very euphoric feeling, “on top of the world,” and being able to do or accomplish anything. Manic Episode: Abnormally and persistently elevated, expansive, irritable Mood Activity Thinking Elevation of mood euphoria elation exaltation ecstasy Psychomotor activity: Increased activity Overachieves Restlessness Manic excitement Based on external cues Speech: • Talkatively • Playful language • Rhyming • Jokes • Loudly speech Thinking: • Rapid • Incoherence • Distractibility Inflated self-esteem or grandiosity: Decreased need for sleep: less than 3 hours feels rested Psychotic symptoms: Delusional ideas Hallucinations Impaired judgment Typical for up to 70% of manic patients Hypomanic episodes: milder form of mania, least four days of the same criteria as mania, does not cause a significant decrease in the individual's ability to socialize or work, lacks psychotic features (delusions, hallucinations), does not require psychiatric hospitalization. WHAT IS DEPRESSION ? depressed mood, loss of interest or pleasure, feelings of guilt, disturbed sleep or appetite, low and poor concentration. Types Major Depression: Classified further on the basis of occurrence a. Single Episode b. Recurrent Types Major Depression: • Single episode - occurs only once and meets all the diagnostic symptoms of major depression • If untreated, 85% of persons who have one episode of depression will have another episode within 10 years • Recurrent-2 major depression episodes, separated by at least a 2 month period • Median number of depressive episodes per person is 4 • 25% have 6 or more episodes Clinical Features of depression: a) strengthening of negative vital emotions (melancholia, grief, sometimes with a shade of fear, anxiety), b) a slower rate of thinking (monoideism, delusions of selfcondemnation), c) deep inhibition of effector-volitional activity (up to stupor), d) riveted attention. Mood and affect: Hopeless, helpless, down, or anxious, May also say that they are a burden on others, a failure at life, or may make other similar statements, Easily frustrated and are angry with themselves or others, Anhedonia, Apathy. Physiologic and self-care considerations: Weight loss (lack of appetite/disinterest in eating), Sleep disturbances (sleepless, or they don’t feel how much time they spend in bed), Decreased libido, Neglect personal hygiene (lack of interest or energy), Constipation, Dehydration. Suicide: • Suicide is the act of willfully ending one's own life. • Suicide is an intended self-damage with fatal outcome. • People, who perform suicide, usually suffer from strong emotional pain and are under stress, as well feel the inability to manage their problems Variants of depression: Anxious-agitated depression: (melancholia with anxious-agitated depression, excitement), Hypochondriacal depression: (numerous unpleasant sensations, without any pathological proses in inner organs), In masked depression: (motor, autonomic and sensitive disturbances prevail as depression equivalents). Biological theories causes: Genetic Hypothesis Biochemical theories Neuroendocrine theories Sleep Studies Brain imaging Psycholosocial theories causes: Psychoanalytic Stress Cognitive and Behavioral theories Triggers of bipolar disorder: Stress Substance Abuse Medication Seasonal Changes Sleep Deprivation Differential Diagnosis: Organical mood disorders Acute/ transient psychotic disorders Schizophrenia Adjustment disorder Generalized anxiety disorder Lifestyle Tips for Bipolar Disorder: Establishing firm routines can help manage bipolar disorder. Routines should include sufficient sleep, regular meals, and exercise. Because alcohol and recreational drugs can worsen the symptoms, these should be avoided. Patients should also learn to identify their personal early warning signs of mania and depression. This will allow them to get help before an episode spins out of control. Pharmacologic Therapy: Mood-stabilizing drugs (lithium, valproate, carbamazepine, and lamotrigine), Atypical antipsychotics (quetiapine, olanzapine, aripiprazole), Benzodiazepines, Antidepressants (Selective serotonin-reuptake inhibitors (SSRIs) like fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram; Tricyclic Antidepressants(TCAs) like amitriptyline; Monoamine oxidase inhibitors (MAOIs), Mood-stabilizing drugs is the primary pharmacotherapy for relapse prevention. Other treatment: Electroconvulsive therapy, Psychosurgery, Psychosocial treatment. Electroconvulsive therapy: Depression with suicidal risk, Severe refractory depression, Delusional depression, Depression with significant antidepressant side-effect. Culture-Related Diagnostic Issues: Afro-Caribeans Northern Europeans Japanese Gender-Related Diagnostic Issues: Females (cycling and mixed states, combine with food disorders), Males (alcoholisation).
