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EPIDEMIOLOGY:
Around 0,3 % population , 60 % mental hospital
in-patients
ETIOLOGY:
I. -Heredoconstitutional factor:
the possibility of schizophrenia:
-one parent (+) , children 7-16 % (+)
-all parent (+) , children 40 %
-monozygotic twin ----85,8 %
-dizygotic twin -------14 %
II. -Psychogenic factor
III. -Exogenic factor
SYMPTOMATOLOGY
-Attention and initiative markedly decrease
-Lazy, lack of self care
-Psychical contact limited,monosyllable, poker face
-Flat affect , emotion difficult to feel, no empaty
-Concentration decrease, discriminative insight disturbed,
but no dementia
-Thought process: association disorders--incoherence,often
with delusion and hallucination. Dereistic thinking, neologisme,
hemmung & sperrung.Sometimes there are depersonalization &
derealization.
-Behavioural symptoms: abulia or hypobulia and also often
impulsivity.
SUBTYPES OF SCHIZOPHRENIA
It's better to look the longitudinal history of the illness.
The classical subtypes of schizophrenia are:
-hebephrenia, catatonia and paranoid type (Kraepelin),
-simplex/simple type ( Bleurer).
Simple type
-slowly beginning, hallucination not frequent/rare,
-limited thought, inability to absstract thought,
-association disorders rare,
-bizzare behavior ass. with emotion,attention & activity.
Hebephrenic type
-rapid disintegration, very disturbed association, a lot of
incoherence, neologisme.
-bizzare delusions, frequent cheerfull hallucinations,
-severe regression, frequent mannerism, deep autism.
Catatonic type
-frequently as stupor or furor catatonic ,
-catalepsy symptoms or flexibilitas cerea.
Paranoid type
-predominant delusions with hallucinations
Schizophreiform disorder
-premorbid tends to normal,
-acute, during 2 weeks untill 6 months
-hazy conciousness,oneroid, double book-keeping
symptom
Schizoaffective type,
-dominant affective symptoms,
Laten type
-unclear symptoms, hide/silent
Residual type
-remission with residual symptoms
DIAGNOSIS
1.Eugen Bleurer: 4 As
Primary symptoms:-association disorders,
-affect disorders,
-autism,
-ambivalence.
Secondary symptoms:-delusions,hallucinations etc.
2.Kurt Schneider:
First rank symptoms:
-halucinations;audible thought, dialogue,commentary
-somatic passivity experience,
-thought process:
-interruption/thought withdrawl,thought broadcast,
-delusional peceptions,
-changing desire-
DIFFERENTIAL DIAGNOSIS
-Mental organic disorders
-Other functional psychosis
-Hysteria/Dissociative dsisorders
-Beliefs, tradition, religious
PROGNOSIS-I
-40% remission-social recovery,60% deteriorated.
-Less than one year 30% full remission,30% social recovery &
30% will be long stay in mental hospital
-Bad prognosis:
flat affect, lack of initiative,depersonalization & derealization,
bad premorbid personality,gradual symptoms too high perso
nal aspiration,signs of hypochondriasis,persistent hallucination,
recovery more than one year, deep regression.
-Good prognosis:
acute,clear affective ..elements, clear anxiety or emotional
signs, cyclothymic premorbid personality, self-accused hallucination,
longer interval of remission.
-Robin & Guze :
Good :good premorbid personality,clear precitating factor,negative
family hystory or affective elements,clouding conciousness, acute
onset, no flatness of affect, paranoid symptoms.
DIGNOSTIC GUIDELINES
Minimal one month at- least one of the following symptoms:
a.thought echo/insertion/withdrawl/broadcast,
b.delusion of control/influence-passivity,
c.comment/dialogue/discussion hallucinations or from the
organs of the body,
d.bizzare delusion
or at least two of the following symptoms:
e.persistent hallucination/delusion/overvalued ideas,
f.interrupted motility thought/insertion-incoherence/neologisme
g.catatonic behavior:excitement,posturing,mutism,negativism
flexibilitas cerea,stupor.
h.negative symptoms :apathy, paucity speech,blunting/
incongruity emotional response,resulting in social withdrawl/
lowering social performance and all of these causing:
i.a significant and consistent change in the overall quality of
some aspect of personal behavior manifest as loss of interest,
aimlessness,idleness,a self absorbed attitude and social
withdrawl
Retrospective:
-prodormal phase/non psychotic:
-loss of interest in works,social activities and personal
appearance and hygiene together with generalized anxiety
and mild depression and preoccupation,before the psychotic
symptoms for some weeks/month
Pattern of course:
-continuosly,
-episodic with progressive deterioration,
-episodic with stable deficit,
-episodic remittent,
-with incomplete remission or
-complete remission.
-other,
-periode of observation less then one year.
Criteria of time for residual schizophenia minimal 1 year and for
schizotypal disorder 2 years, if the psychotic phase not yet 1
month, the preliminary diagnosis is Acute Schizophrenic-like
Disorder.
Subtypes of schizophrenia
F 20.0 Paranoid schizophrenia
The general criteria for a diagnosis of schizopheni must be satisfied.In addition,
hallucinations and/or delusions must be prominent,and disturbances of affect,
volition and speech,and catatonic symptoms must be relatively inconspicious.
Delusions can be of almost any kind but delusions of control,influence,or passivity,
and persecutory belief of various kinds are the most characteristic.,
F20.1 Hebephrenic schizophrenia
A form of schizopohrenia in which affective changes are prominent,delusions and
hallucinatons fleeting and fragmentary,behaviour irresponsible and unpredictable,
and mannerisms common.The mood is shallow and inappropriate and often
accompanied by giggling or self-satisfied,self-absorbed smiling,or by a lofty
manner, grimaces, mannerisms,pranks,hypochondriacal complaints,and reiterated
phrases. Thought is disorganized and speech rambling and incoherent.There's a
tendency to remain solitary, and behaviour seems empty of purpose and feeling.
Usually starts between the age of 15 and 25 years and gendss to have a poor
prognosis because of the rapid development of negative symptoms,particularly
flattening of affect and loss of volition.
F 25 Schizoaffective disorders
These are episodic disorders in which both affective and schizophrenic symptoms are
prominent within the same episode of illness,preferably simultanously,but at least
within a few days of each other.
F 25.0 Schizoaffective disorder,manic type
There must be a prominent elevation of mood,or a less obvious elevation of mood
combined with increased irritability or excitement.Within the same episode,at least one
and preferably two typically schizophrenic symptoms should be clearly present.
F 25.1 schizoaffective disorder,depressive type.
A disorder in which schizophrenic and depressive symptoms are both prominent in the
same episodes of ilness.Depression of mood is usually accompanied by several
characteristic depressive symptomsor behavioural abnormalities such as retardation ,
insomnia, lost of energy, appetite or weight reduction of normal interests,impairment
of concentration guilt,feelings of hopelessness,and suicidal thoughts.At the same time
or within the same episode,other more typically schizophrenic symptoms are present.
This subtype usually less florid and alarming than manic type,but they tends to last
longer and the prognosis is less favourable.Although the majority of patients recover
completely,some eventually develop a schizophrenic defect.
F 25.2 Schizoaffective disorder,mixed type
Disorders in which symptoms of schizophrenia coexist with those of a mixed bipolar
affective disorder.
MOOD (AFFECTIVE)
DISORDERS
AFFECTIVE DISORDERS
A group of mental disorders with the
main disturbances in the affective
aspect, with or without psychotic
features,no signs of schizophrenia and
can exacerbate periodically.
Mood fluctuation:
ecstasy---------------exaltation-------------- hyperthymia
""""euphoria.........""""""""""""""""
"""""""""""""""""""""""""""""""""""""""""
------ happy/cheerful-------------n o r m a l ------------- normo/euthymia
------sadness-----------------""""""""""""""""""""""""""""""""""""""""""
depression-------------------------- hypothymia
suicidal-------------------
Etiology:
Mostly endogenous ( 25x ----------> in sibling and 50%
in monozygotic twin
Epidemilogy:
~ 2-36 in 100.000 population
~ 3x in high societies & professionals
~ women 2x men
~ 5-15% of psychotic patients in mental hospital
Precipitating factors:
Loss one of the valuable objects e.g:
-death,
-failures in interpersonal relationship,
-frustation associated with loyalty
SYMPTOMATOLOGY
The symptoms in the affective aspect,
thought process and behavioral
although pathological but more or less
is still harmonious and it's clearly apart
between manic & depression.
MANIC EPISODE
-afect---elated
-rare hallucination (mostly flattery/praise)
-associations:-flight of ideas,logorrhoe-clangassociations
-thought contents : expansive hallucinations
(megalomania),
non-systematic,wishfullfilling,sometimes persecutory
delusions,
-hyperactivity ,singing,dancing,shouting, impolite,
unproperly,
irritable, lack of sleep and never being tired/exhausted,
attention easily changed, many plans but never
finished.
-mild condition:
-hypomania: mild type e.g: talk too much,busy,self
confidence, self pride, agressive,irritable,argumentative,
extravagance,more chronic,.becoming milder
-impression: overconfident but actually overdependent
PROGNOSIS
-early onset 20-25 years, if younger will be worse
-more acute will be better
-more often excarcerbation tends to poor prognosis
-mixed with schizophrenic symptomsnot good
-without therapy the attack last about 6 months
-difficult to prevent excacerbation even with good drugs
-chronic condition rarely before 40 years
DEPRESSION EPISODE
-affect : hypothymia,with pessimism,annoyed&gloomy
-association not smooth with hemmung & sperrung,
monosylable talked,sometimes no voices
-thought content: ideas of guilty feeling and sin,
hypochondriasis, self-accused and nihilistic delusions,
paranoid idea, hallucinations followed the affect until
suicidal thought,
-behavior:hypoactive sometimes until stupor,refuse to eat &
drink and resulting dehydration,
-sometimes homiside as an extention from the suicidal act &
it happened when the motoric retardation reduces but the
suicidal thoght still present,often in condition with anxiety
& positive family history.
PROGNOSIS
-early onset 30-35 years
-more younger the prognosis will be worse
-if depression come firstly, it's uncertain will be back again,
-mostly more endogenusly, the prognosis will be worse,
-growing older the depression will be more often,
-without therapy the recovery needs 9 months,
-more acute will be better, more chronic become milder,
-more often means worse
-compared with mania this type tends to become chronic,
-hypochondriasis & severe nihilism with a lot of anxieties
means poor prognosis.
Classification:
F30 Manic episode include hypomania
F31 Bipolar affective disorder,with recent
episode manic/depression /mixed
F32 Depressive episode
F33 Reccurent depressive disorder
F34 Persistant affective disorders include
cyclothymia and dysthymia
F38 Other mood (affective) disorders.
F39 Unspecified mood (affective) disorders
In hypomania:
-milder than mania,
-at least for several days
-intensity more then cyclothymia
Manic episode:
-acute, duration 1-2 weeks untill 4-5 months
Depressive episode:
-longer,duration about 2weeks untill 6 months rarely
more then 1 year except in old age
-Often begins with stress but not always, specifically:
full recovery between episode.
Diagnosis:
-for bipolar minimally there should be once for other
affective episode.
Bipolar Disorder Is
Multidimensional
Mania
Subsyndromal Mania
(Hypomania)
Mania
Maintenance
Subsyndromal Depression
(Dysthymia)
Depression
DELUSIONAL ( PARANOID )
DISORDERS
PARANOID DISORDERS
A group of severe mental diorders with the main symptoms
is a variety of delusions, often systematic with or without
hallucinations.
The psychotic symptoms often very clear & sometimes
only delusions which is dominant.
Since Hippocrates,paranoia means "sanity",used again by
Vogel, and more confirmed by Kahlbaum (1863).
Kraepelin: introduce the term paraphrenia and there're 4
type: systematic,expansive,confabulative and fantastic.
Freud: paraphrenia is identically the same as paranoid
schizophrenia.
EPIDEMIOOGY
Prevalence (USA) 0.025-0.03% ( Schizophrenia 0.1 %
and affective disorders 0.5%).Women twice than men
and usually single and suspected with homosexual
orientation and chronic prejudice.
ETIOLOGY
-Psychogenic cause: frustated ambition drive
-Freud :homosexual fixation
-sadistic experiences during early childhood
( anal sadistic phase)
-Genuine paranoid rarely seen,usually an extension of
paranoid premorbid personality.
-more often in the form of paranoid reaction,
-the defence mechanism which is used: denial &
projection
-Heriditary / constitutional e.g:
-low threshold for frustation,
-rigid in relationship,
-hypersensitivity etc.
SYMPTOMS
The main symptoms:delusions,logic,sistimatic,complex,sometimes
looks like isolated /apart from the personality,so the personality seems
intact, and disturbed when the delusions being touch.
-Persecuted delusions:feels being hatred- by relatives,want to be
unmistakeable, the misintepretation & misunderstanding resulting in
persecuted delusions.
-Delusion of reference if there's a feeling that someone is talking or
commenting obout him/her
-Litygious type: feeling of being treated unfair,feeling of being right and
superior.
-Exaltase type:delusions of grandeur,megalomania,often appear long
time after persecuted delusions, often feels as Gods mission
-Erotic type:feeling the celebrities fall in love with him/her.
Often appear as suicidal homocidal action.
INVOLUTIONAL PARAPHRENIA
Rarely genuine,often mixed wirth melancholia
Premorbid full of defence mechanism projection,
inferior,critical,tends to blame others,jealous,
cannot forgive,suspicious.
Symptoms:-organized persecutory delusion,
annoyed, feeling of hostility.
Prognosis:-worse than involutional melancholia
GOLONGAN ANTIDEPRESAN
1.Golongan ikatan trisiklik
-amitriptyline : tablet 25 mg
-imipramine: tablet 10 mg; 25 mg
-tianeptine: tablet 12,5 mg
2.Golongan ikatan tetrasiklik
-maprotiline : tablet 25 mg; 50mg
-mianserine: tablet 10 mg; 30 mg
-amoxapine: tablet 100 mg
3.Golongan Mono Amine Oxidase Inhibitor (MAOI)Reversible
-moclobemide: 150 mg
4.Golongan Selective Serotonin Reuptake Inhibitor (SSRI)
-sertraline: tablet 50 mg
-fluoxetine: tablet 20 mg
-paroxetine : tablet 20 mg
-fluvoxamine: tablet 50 mg
-citalopram : tablet 20 mg
5.Golongan antidepresan atipikal
-mirtazapine: tablet 15mg; 30mg; 45 mg
-duloxetine: tablet 60mg; 120mg
-venlafaxine Hcl: tablet 75mg; 150mg; 225mg
OBAT ANTIMANIK
1.Mania akut:
-haloperidol:tab 0,5mg; 1,5mg; 2mg; 5mg
-carbamazepine: tablet 200mg
-valproic: tablet 200mg
-lithium carbonate: tablet 200 mg
2.Profilaksis: -lithium carbonate tablet 200mg