Psychotic Syndromes · 12:04pm Sep 20th, 2013

Alright all you wannabe psychopathology writers, time to get schooled!

Psychotic Syndromes
Humour Disorders
Anxiety, Dissociative and Somatoform Disorders
Personality Disorders
Eating Disorders
The concept of normality: A psychopathological approach
Organic Mental Disorders

The psychotic syndromes are characterized by changes in the behavior, distortions in the perception of reality and an inadequate affection. The most important psychopathological phenomena are: delusional ideas, hallucinations, incomprehensible speech and socio-occupational losses. The psychotic disorders can have acute or chronic evolution. The psychotic episodes related to external causes, such as medication and drug use, alcoholism and medical diseases (tumors, encephalitis, rheumatological and endocrine diseases, etc.) are more acute and their duration depends on the adequate treatment and the removal of the basal cause. The psychotic syndromes that aren’t related to external causes constitute properly-said psychiatric disorders, of which schizophrenia is the most common and important of this group.

I - Schizophrenia
Schizophrenia is a grave, heterogeneous disorder with no known cause. It courses with psychotic symptoms that significantly diminish the social capacity of the individual. They have chronic evolution and, most of the time, have a dark/somber prognosis. The schizophrenic disorders are described, in general, as characteristic disorders of the thought, perception and affection. The clear conscience and the intellectual capacity usually are maintained, although cognitive deficit can happen with the disease’s evolution.

Epidemiology
Schizophrenia is a disease with universal distribution that mainly affects the younger population. It can happen in both sexes at the same rate, varying, however, on when the disease first manifests itself. In the male gender, the disease happens much earlier (10-25 years) while in women, some years after (25-35 years). Approximately 90% of the patients being treated are between 15 and 55 years old. It is rare to see the condition first manifesting itself after 60 years of age and before 10 years of age. It is considered that the disease has a prevalence of 1% in the worldwide population. There appears to be no difference in the incidence of schizophrenia between social classes, urban or rural areas, developed or emerging countries.

Etiology
Although considered a “single disease”, this diagnostic category includes a plethora of disorders, probably with heterogenous causes, but with a similar symptomatic. Schizophrenia covers patients with varying clinical manifestations, response to treatment and disease evolution. Thus, no isolated etiological factor is considered as the source. The etiological model used most frequently is the stress-diathesis, according to which, the individual that develops schizophrenia has a specific biological vulnerability (diathesis) that, when activated by stress, allows the symptoms to flourish. The stressors can be genetic, biological, psychosocial or environmental.

Genetic factors
Various studies suggest a genetic component in the etiopathogeny of this disorder. It has been observed that the incidence in families is greater when comparing to the general population and that the concordance between monozygotic twins is bigger than dizygotic twins. Not only that, the study with adoptive children indicates that the risk is associated with the presence of schizophrenia on the biological parents; the fact that you live with a schizophrenic doesn’t seem to make your chances of developing the disorder higher.

Neurobiological factors
The dopaminergic theory postulates that schizophrenia is the result of a higher dopaminergic activity in the brain. This theory is based on the fact that most antipsychotic drugs are related to their functional mechanism as antagonists of the dopamine receptor type-2 (D2). The higher dopaminergic activity caused by some drugs (such as cocaine and amphetamines) and how they make psychotic symptoms appear or made worse also support this hypothesis. It is also known that the mesocortical and mesolimbic dopaminergic tracts of the central nervous system (CNS) play a significant role in schizophrenia’s physiopathology. Thus, we can assume that, although not completely clear, the dopaminergic functions show important symptomatic manifestations in schizophrenia. Even so, other neurotransmitters have been studied as well. Such studies show that there is an interaction of multiple systems of neurotransmitters in the regulations of the signs and symptoms of schizophrenia, especially the serotoninergic system.

Neuropathic and neurochemical alterations, especially on the limbic system and in the basal ganglia, have been thoroughly researched regarding their possible implications in the development of schizophrenia. Neuroimaging and electrophysiology studies have also been used.

Psychosocial factors
Lots of theories have discussed the role of psychodynamic factors in the developing of schizophrenia. In this regard, the central dimension of the psychosis is related with the loss of contact with reality. Familiar, social and individual factors appear to be fundamental factors in the understanding of the dynamics of the patient and their psychological conflicts and, consequently, the symbolic meaning of their symptoms.

Clinical Manifestations
The clinical spectrum of schizophrenia is very polymorphic and heterogeneous. There is no pathognomonic symptom or sign of schizophrenia and the psychiatrist must take into account the educational level, intellectual capacity and the cultural environment of the patient. Not only that, but the symptoms can change as the clinical course evolves.

Pre-morbid personality
The characteristic traits are social and emotional retracement, introversion, tendencies to isolation and wary and eccentric behaviors. They are people with few friends and that have shown difficulties during school and difficulties regarding relationships with the opposing gender. On many times, they also cannot adapt to their work environment, being unable to keep a lasting employee-employer link. With this, we can retrospectively observe clinical characteristics compatible with schizoid personality (emotional coldness, preferring lone activities, introspection, etc.) or schizotypal personality (weird behavior, eccentric beliefs, etc.)

Signs and symptoms
The schizophrenic patient seldom has a critical thinking about his pathology (this lack of insight is often linked with therapeutic failure). Although the conscience level, space-time orientation, memory and intelligence aren’t directly affected, many times the patient has alterations in these psychic functions that are caused by the psychotic episode they are currently living.

General aspects
The patient often neglects its physical appearance, showing the absence of self-care. The behavior can become agitated or violent, frequently due to hallucinatory activity. In the catatonic states, the patient can have weird poses, mutism, negativism and automatic obedience. Other behaviors include: stereotypical behavior, mannerisms, ticks and echopraxia (in which the patient mimics the posture or gestures adopted by its examining doctor).

Affection
The affection symptoms that are most common in schizophrenia are inappropriate and dull affection. Perplexity, ambivalence or affective instability can also be observed.

Sensoperception
Any of the senses can be affected by hallucinatory experiences. The most common hallucinations are the auditive ones, usually with threatening, obscene or accusatory voices. Two or more voices can speak amongst themselves or one voice can comment on the actions, life and thoughts of the patient. Cenesthetic hallucinations are altered perceptions of one’s own organs and the body as a whole (for instance, a patient can feel one’s own brain shrinking, its liver being torn to pieces or he/she can be aware that someone stole his/her bones). Visual, tactile, olfactory and gustatory hallucinations can also happen, but usually indicate the presence of a psycho-organic syndrome or of a drug-triggered psychosis.

Thoughts
Delusions are one of the main alterations of thoughts found in schizophrenic patients. They can have persecutory, self-referencing, religious or grandeur content. The patient can also believe that his thoughts or behaviors are controlled by an external entity (influence delusions). The thoughts can show themselves as unorganized, with episodes of thought-stealing, diffusion of thought (his thoughts are being transmitted to others) or blockage of thought. Other alterations include thinly-made associative nexus, incoherence and tangentiality.

Language
Neologisms and echolalia can be observed, very much like mutism episodes. The mussitation is the repetitive production of a low voice, almost a whisper, in monotone, without any communicational significance as if he/she was talking to him/herself, and can be found with frequency in schizophrenia.

Diagnosis
The diagnosis is phenomenological, based on the description and observation of the patient. Many diagnostic systems, based on many clinical descriptions, are used. The schizophrenia diagnosis involves the recognition of a plethora of signs and symptoms associated with occupational and/or social lower capacity. There isn’t, still to this day, no complementary exam that can identify schizophrenia. The complementary exams must only be solicited to make a differential diagnosis of the psychotic syndromes associated with other medical conditions.

The precise definition of schizophrenia, its fundamental and characteristic symptoms and what is most peculiar or “central” is still a reason for intense debate in psychopathology. There isn’t any sign or symptom that is pathognomonic of schizophrenia: instead, a group of characteristic findings makes the diagnosis. The most important definitions of schizophrenia are presented below:

Eugen Bleuler (1857-1939)
He coined the term schizophrenia trying to indicate the lysis between thought, behavior and emotion of the patients with this disorder. He classified the symptoms between fundamental and accessories. The first group is characteristical of this disease, while the second group can happen in other psychiatric pathologies.

Fundamental symptoms
Formal alterations of the thought process (thinly-created and disassociation of the associations), perturbations in the affection, autism (such as tendencies to being psychically and globally isolated) and ambivalence. These are the “Four A’s of Bleuler”: Association; Affection; Autism; Ambivalence.

Accessories symptoms
Sensoperceptive alterations, delusions, catatonic symptoms and memory and attention disorders.

Kurt Schneider (1887-1967)
Established a hierarchy of symptoms according to their importance to the diagnosis of schizophrenia, such as the following:

First Order Symptoms
Delusional perception; voices that talk amongst themselves; voices that comment about the patient; episodes of corporeal influences; episodes of thought influences; sonorization and diffusion of thought; all other alterations involving volition, affection and influenced impulses.

Second Order Symptoms
Other sensoperception disorders; perplexity; manic or depressive alterations in the humour; affective impoverishment; other symptoms.

The first order symptoms are considered very suggestive of schizophrenia, as long as organic causes are excluded. The second order symptoms have a lesser diagnostic value. Even so, Schneider himself said that the presence of first order symptoms is not necessary to diagnose schizophrenia.

Another classification of schizophrenia regards the positive (type 2) and negative (type 1) symptoms

Negative symptoms
They are defined as a lack of psychic functions and by a global impoverishment of the psychic and social life of the individual. The main ones are as follows:
- Dull affection: loss of the capacity to emotionally bind with people; the loss of capacity to demonstrate affective resonance in the interpersonal contact. This corresponds to what Bleuler called autism.
- Social retraction: the patient isolates himself more and more from the social life.
- Impoverishment of language and thought
- Lower verbal fluency
- Lower volition and pragmatism: that is, the difficulty or inability to perform tasks or actions that require the minimal persistence and initiative.
- Self-negligence: lack of hygiene and self-care; lack of interest for the self-image; etc.
- Psychomotor lentification

Positive symptoms
These are “productive” manifestations of the schizophrenic process. The main ones are as follows:
- Auditive (most frequent), visual or other types of hallucinations.
- Delusional paranoid, self-referencing, of influence or of other nature ideas.
- Bizarre behavior and impulsive acts.
- Psychomotor agitation
- Bizarre ideas, not necessarily delusional
- Linguistic productions (such as neologisms)

Both the ICD-10 (symptoms must last, at least 1 month) and the DSM-IV (symptoms must last, at least 6 months) have different diagnoses criteria for schizophrenia (both using the positive and negative symptoms). The ICD-10 (most used one), however, classifies schizophrenia a little bit further:

Paranoid schizophrenia
The most common form of schizophrenia. It tends to manifest itself later than the catatonic and hebephrenic forms, something that guarantees that the patient may remain more preserved. The clinical picture is characterized by the presence of delusional ideas (mainly with persecutory, of grandeur or mystical content), followed by auditory hallucinations and alterations in the sensoperception. The hallucinatory voices usually have a threatening or commanding quality. Influences of thought/act are common. Affection, volition and psychomotor alterations aren’t proeminent.

Hebephrenic schizophrenia
Characterized by inadequation and incongruence of the affection, with unmotivated laughter and mannerisms. The delusion is very fragmented and there is a grave disorganization of the thought. The speech tends to be incoherent. Auditory hallucinations may occur. The behavior is most often puerile and inappropriate. This kind of schizophrenia is the most grave one and tends to develop before 25 years of age. There is a tendency to social isolation. The prognosis is often dark, due to the intense lack of psychic structure and the presence of negative symptoms, especially the dull affection and the lack of volition.

Catatonic schizophrenia
The most prominent symptoms are those regarding to the psychomotor skills and one or more of these symptoms: estupor, bizarre postures, mutism, rigidity, automatic obedience, negativism and stereotypical behavior. Episodes with violent agitation and impulsivity can be observed. The differential diagnosis includes: infectious diseases and intoxications (especially due to neuroleptic drugs).

Undifferentiated schizophrenia
This category is used when the symptoms match those of schizophrenia and either cannot be put under any class or can be put into more than one class at the same time.

Residual schizophrenia
The late stage in many cases, characterized by the presence of, mostly, negative symptoms.

Simple schizophrenia
Characterized by the insidious and progressive start of the weird conducts and incapacity to meet society’s demands. The negative aspects of residual schizophrenia manifest themselves without being preceded by whichever psychotic manifestations.

Post-schizophrenia depression
It’s the denomination for the depressive state that happens at the end of a schizophrenic episode. Although positive and/or negative symptoms can still be present, they do not dominate the patient’s clinical picture. This type of depressive state accompanies a high risk of suicide. If there is no psychotic symptoms present, the diagnosis of a depressive episode must be made. Otherwise, the schizophrenia diagnosis must be kept.

Prognosis
Prodromic symptoms of anxiety, perplexity or depression usually precede the start of the disease and can be present for months before a diagnosis can be made. The start of the disease tends to happen between 20-25 years. Triggering effects, such as emotional trauma, drug use and separations can cause the symptoms in predisposed individuals. Classically, the course of this disease consists in exacerbations and remissions. Every single remission is followed by an additional deterioration of the basic functioning of the patient. Vulnerability to stress is maintained. During the course of the disease, the most exuberant positive symptoms (such as delusions and hallucinations) tend to lower their intensity, while negative symptoms tend to grow stronger.

II - Other Psychotic Disorders
Persistent Delusional Disorder
This is characterized by the presence of a delusional and indestructible idea. The delusions can be of persecution, of jealousy, of erotomania, amongst others. The symptoms differ from those of the schizophrenic delusion due to their non-bizarre nature and the absence of both hallucinations and dull affection. The patient’s emotional response to the delusional system is congruent and adequate to the contents of the delusion. The personality remains intact or suffers a minimal jeopardy. The patients are usually wary of others and hypervigilant, something that can lead to social isolation, even though they still have capacity for social functioning. The age varies between 20-90 years (middle ground is 40 years). The etiology is still unknown.

Schizophreniform Disorder
This is characterized by a clinical course that is similar, in all aspects, to schizophrenia. The only difference is that they last more than one month, but less than six. They all return to normal functioning.

Schizoaffective Disorder
This is defined as a disorder in which the affective and schizophrenic symptoms are both equally prominent, making those who fall under this class unable to be diagnosed with either schizophrenia or mood disorders.

Short Psychotic Disorder
This is characterized by symptoms that last for more than a day but less than a month and happen after an evident stress in the patient’s life. The symptoms are similar to other psychotic disorders, although with more instability, volatility and disorientation. Organic causes, such as intoxications, drug abuse, epilepsy, dissociative disorders and simulations must be discarded. It is also named Polymorphic Acute Psychotic Disorder, due to the symptom instability, which can change very quickly.

Schizotypal Disorder
This is characterized by an eccentric behavior and alterations in both the thought and affection that are similar to those of schizophrenia without, however, characteristic signs of schizophrenia. The symptoms can show inappropriate affection, tendencies to back from social interaction, eccentric behavior and bizarre ideas that cannot be classified as delusional.

Stay tuned for next season: when I talk about clinical depression, mania and mood disorders (manic-depressive psychosis {bipolar disorder} included).

Also: Eating is for wimps and dermatologists.