SPECTRUM

DISORDERS and
other PSYCHOTIC
DISORDERS

Contents
Introduction
History
Recent

statistics
Etiological Factors
Clinical Features

Introduction
Schizophrenia

is a
clinical syndrome of
variable, but profoundly
disruptive,
psychopathology that
involves cognition,
emotion, perception,
and other aspects of
behavior.

The

expression of these
manifestations varies
across patients and over
time, but the effect of the
illness is always severe and
is usually long lasting. The
disorder usually begins
before age 25, persists
throughout life, and affects
persons of all social classes.

Both

patients and their

families often suffer from
poor care and social
ostracism because of
widespread ignorance about
the disorder. Although
schizophrenia is discussed
as if it is a single disease, it
probably comprises a
group of disorders

with

heterogeneous etiologies,
and it includes patients whose
clinical presentations, treatment
response, and courses of illness
vary.
Clinicians should appreciate that
the diagnosis of schizophrenia is
based entirely on the psychiatric
history and mental status
examination. There is no
laboratory test for schizophrenia.

tories of Schizophreni

Emil

Kraepelin
translated Morel's
dmence prcoce into
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.

Eugene Bleuler
Bleuler

coined the term

schizophrenia, which
replaced dementia precox
in the literature. He chose
the term to express the
presence of schisms
between thought,
emotion, and behavior in
patients with the disorder.

Bleuler

stressed that, unlike

Kraepelin's concept of
dementia precox,
schizophrenia need not have a
deteriorating course. This term
is often misconstrued,
especially by lay people, to
mean split personality. Split
personality, called dissociative
identity disorder

The Four As
associational

disturbances of thought,
especially looseness,
affective disturbances,
autism, and
Ambivalence
Bleuler also identified accessory (secondary)
symptoms, which included those symptoms
that Kraepelin saw as major indicators of
dementia precox: hallucinations and delusions.

Kurt Schneider

Schneider contributed a
description of first-rank
symptoms, which, he stressed,
were not specific for
schizophrenia and were not to
be rigidly applied but were
useful for making diagnoses. He
emphasized that in patients
who showed no first-rank
symptoms, the disorder could
be diagnosed exclusively on the
basis of second-rank symptoms
and an otherwise typical clinical
appearance.

 Clinicians

frequently ignore his warnings

and sometimes see the absence of firstrank symptoms during a single interview
as evidence that a person does not have
schizophrenia.

Kurt Schneider Criteria for Schizophrenia

1.First-rank symptoms
1.Audible thoughts
2.Voices arguing or discussing or both
3.Voices commenting
4.Somatic passivity experiences
5.Thought withdrawal and other
experiences of influenced thought
6.Thought broadcasting
7.Delusional perceptions
8.All other experiences involving
volition made affects, and made
impulses

1.Second-rank symptoms
1.Other disorders of perception
2.Sudden delusional ideas
3.Perplexity
4.Depressive and euphoric mood
changes
5.Feelings of emotional
impoverishment
6.and several others as
well

Schneider first rank symptoms

of schizophrenia
Individual

symptoms
that are highly specific
for schizophrenia
in about 80% of
schizo pts, 40% in
bipolar mood disorder
( only mania)& 20% in
severe major depression

Occur

Schizophrenia

Gender and Age

Schizophrenia

is equally prevalent in
men and women. Onset is earlier in
men than in women.
Approximately 3 to 10 percent of
women with schizophrenia present with
disease onset after age 40. About 90
percent of patients in treatment for
schizophrenia are between 15 and 55
years old.
Onset of schizophrenia before age 10 or
after age 60 is extremely rare.

Some

studies have indicated that men

are more likely to be impaired by
negative symptoms than are women and
that women are more likely to have
better social functioning than are men
prior to disease onset. In general, the
outcome for female schizophrenia
patients is better than that for male
schizophrenia patients. When onset
occurs after age 45, the disorder is
characterized as late-onset
schizophrenia.

In Malaysia
Incidence and prevalence(In Malaysia)
Lifetime prevalence 1-1.5%
There is 7351 cases had been reported from 20032005
The incidence was noted higher in males, urban and
migrant population
Sex ratio
60% of the schizophrenia cases are man
Socioeconomic status
Prevalence > low socioeconomic groups
Age of onset
Common between 15 and 35, rare before 10 and
after 40 years old. Earlier onset for

Epidemiology: Sex

Philippines
Local

figures are unavailable but

Philippine Health Statistics said
authorities are alarmed at the
increasing suicide rate in the country.
In 2000 alone, there were 1.8 deaths
from suicide per 100,000 population.
Suicide is common in people with
schizophrenia.

According

to the World Health

Organization, schizophrenia is
one of the top 10 causes of
disabilities in developed
countries.

disability survey made by the

National Statistics Office (NSO)
showed it is among the third
most common form of
disabilities with a prevalence
rate of 88 cases per 100,000
population.

The

region with the highest

prevalence rate is Southern
Tagalog at 132.9 cases per
100,000 population, followed by
NCR at 130.8 per 100,000
population and Central Luzon at
88.2 per 100,000 population, the
NSO revealed.

Philippine study conducted in three

primary health centers in urban slum in
Manila in 1993-1994 showed that 17 % of
adults and 16 % of children had mental
disorders. Prevalence of mental health
disorders was at 35%. A study conducted
by the University of the Philippines
Department of Psychiatry in the rural areas
in 1989 yielded similar findings, where
34% of those with mental disorders had
social problems.

The

three most frequent diagnoses

among the adults were: psychosis
(4.3%), anxiety (14.3%) and panic
(5.6%). For children and adolescents,
the top five most prevalent psychiatric
conditions were: enuresis (9.3%),
speech and language disorder (3.9%),
mental sub-normality
(3.7%), adaptation reaction (2.4%)
and neurotic disorder (1.1%)

study performed in the 1970s even

showed that 12 out of 1000 Filipinos
have severe mental disorder, quite
an alarming rate if compared with
the internationally recognized rate of
1/1000.

In the past three decades, Filipinos have been

exported as work force abroad in the light of
economic justifications to support their
families. Of the 7.76 million Filipinos overseas
in 197 countries, 2.86 million immigrants or
permanent residents, 3.38 million
documented OFWs, and 1.5 million irregularly
documented overseas workers. 75% of these
workers are women, majority of which work
as domestic helpers in countries such as Saudi
Arabia, Taiwan, UAE, Hong Kong and Kuwait.

Seafarers,

mostly male workers, find it most

difficult during long periods of isolation out
at sea specially those who work in cargo
ships and tankers, in contrast to those who
work on cruise liners whose ships dock
more often, allowing them to interact with
other people almost everyday.
Filipinas working as domestic helpers
abroad are exposed to situations that render
them vulnerable to physical, sexual and
psychological abuses.

In 2007, reported by Philippine

Star
Cases

of mental illness in the country are on

the rise with the increase in population,
reporting that the most common disease is
schizophrenia which affects one percent of the
total population.
Dr. Noel Reyes, a psychiatrist at the National
Center for Mental Health in Mandaluyong City,
said one of the most common brain diseases
among Filipinos is schizophrenia, which afflicts
one percent of the total population.

Increase

in the incidence of
mental illness was also due
to the widespread use of
prohibited drugs.
He said the Dangerous
Drugs Board recently
released data, which shows
that eight million Filipinos
are drug users.
Most common in seafarers.

At

the GMA News online hub, (2008)

there is was an article entitled "1 in 5 adult
Pinoys have psychiatric disorders. It
further says that more people are
developing mental disorders due to
extreme life experiences.
between 17 to 20 percent of the countrys
adult population have psychiatric
disorders.
About 10 to 15 percent of children aged 5
to 15 are believed to have mental problems.

Etiology

Genetic Theories
Schizophrenia

occur at an
increased rate among the
biological relatives of
patients with schizophrenia.
The likelihood of a person
having schizophrenia is
correlated with the
closeness of the
relationship to an affected
relative (e.g., first- or
second-degree relative). 3-

Genetics Twin Studies

Gottesman

1991 suggests that

schizophrenia is inherited
through genes. Studied 40 twins
- the concordance rate for MZ
twins is about 48% and only
about 17% for DZ twins.

Also

Cardno 2002 showed

concordance rate of 26.5 MZ
and 0% for DZ.

Genetics Family Studies

Gottesman

also studied families he

concluded that if both your parents
suffer from Schizophrenia, then you
have a 46% chance of developing it
yourself (compared to a 1% chance of
someone selected at random will
suffer)

The

more genetically similar relatives

are, the more concordance is found.

Polygenic Transmissions
Reports

on chromosome 5 are associated

with some pattern of familial transmission.
Eye Movement Dysfunction- Various
studies have reported abnormal eye
movements in 50 to 85 percent of patients
with schizophrenia, compared with about
25 percent in psychiatric patients without
schizophrenia and less than 10 percent in
nonpsychiatrically ill control subjects.

In

studies of schizophrenic
patients with no history of illness
in either the maternal or paternal
line, it was found that those born
from fathers older than the age of
60 were vulnerable to developing
the disorder. Presumably,
spermatogenesis in older men is
subject to greater epigenetic
damage than in younger men.

Developmental Theories
Birth

Season- Persons who develop

schizophrenia are more likely to
have been born in the winter and
early spring and less likely to have
been born in late spring and
summer.

In

the Northern Hemisphere,

including the United States, persons
with schizophrenia are more often
born in the months from January to
April. In the Southern Hemisphere,
persons with schizophrenia are more
often born in the months from July
to September. Season-specific risk
factors, such as a virus or a seasonal
change in diet, may be operative.

Another

hypothesis is that
persons with a genetic
predisposition for
schizophrenia have a
decreased biological
advantage to survive seasonspecific insults.

Prenatal
Gestational

and birth complications,

exposure to influenza epidemics, or
maternal starvation during pregnancy,
Rhesus factor incompatibility, and an
excess of winter births is implicated. The
nature of these factors suggests a
neurodevelopmental pathological process
in schizophrenia, but the exact
pathophysiological mechanism associated
with these risk factors is not known.

Evidence

that prenatal malnutrition may

play a role in schizophrenia was derived
from the studies of the Dutch Hunger
Winter of 1944 to 1945. Severe caloric
restriction in the western Netherlands
was associated with substantially
decreased fertility, increased mortality,
and diminished birth weight.

Biological
Explanations
Genetics
Bio chemicals
Brain Structure

DOPAMINE
HYPOTHESIS

Biochemical Factors The Dopamine

Hypothesis
This

theory claims that excessive

amounts of dopamine or an
oversensitivity of the brain to
dopamine is the cause of schizophrenia

There

is strong empirical support

which suggests that dopamine plays an
important role in schizophrenia e.g
drugs which block dopamine
(Phenothaiazines) also seem to reduce
the symptoms of schizophrenia.

Normal Level of
Dopamine In The
Human Brain

Elevated Level of
Dopamine In The Brain of
a Schizophrenic Patient
(specifically the D2
receptor)

Neurons that use the transmitter dopamine fire too often

and transmit too many messages or too often.
Certain D2 receptors are known to play a key role in guiding
attention.
Lowering DA activity helps remove the symptoms of
schizophrenia

DOPAMINE HYPOTHESIS
The Dopamine hypothesis states that
the brain of schizophrenic patients
produces more dopamine than normal
brains.
Evidence comes from
studies with drugs
post mortems
pet scans

POST MORTEM

Falkai et al 1988
Autopsies have found that people with
schizophrenia have a larger than usual
number of dopamine receptors.
Increase of DA in brain structures and
receptor density (left amygdala and
caudate nucleus putamen)
Concluded that DA production is
abnormal for schizophrenia

Parkinsons disease
Parkinsons

sufferers have low

levels of dopamine
L-dopa raises DA activity
People with Parkinson's develop
schizophrenic symptoms if they
take too much L-dopa

Chlorphromazine (given to schizophrenics)

reduces the symptoms by blocking D2
receptors

PET SCANS
Lindstroem et al (1999)
Radioactively labelled a chemical L-Dopa
administered to 10 patients with
schizophrenia and 10 with no diagnosis
L-Dopa taken up quicker with
schizophrenic patients
Suggests they were producing more DA
than the control group.

Other

neurotransmitter
abnormalities implicated in
schizophrenia:
elevated serotonin.
elevated norepinephrine.
decreased gammaaminobutyric acid
(GABA).

Anatomical abnormalities
Enlargement

of lateral ventricles
Smaller than normal total brain
volume
Cortical atrophy
Widening of third ventricle
Smaller hippocampus

Brain Structure
People with schizophrenia
have abnormally large
ventricles in the brain.
Ventricles are fluid filled
cavities. This means that
the brains of
schizophrenics are lighter
than normal.

Brain Structure Evidence

Andreasen

et 1990
conducted a very well
controlled CAT scan study and
found significant enlargement
of the ventricles in
schizophrenics compared to
controls.

However

this was only the

case for men and not for
women. Therefore cant
generalise to everyone.

Further Evaluation
The

main problem with such

studies is that it is not found in all
schizophrenics. This has lead to
further research done by Crow
1985.

He

suggested two types of

schizophrenia with two biological
causes.

Two Syndrome Hypothesis - Crow 1985

Type

one - genetically inherited

associated with dopamine
characterised by positive symptoms.

Type

Two Neurodevelopmenal
disorder to do with Brain structure
characterised by negative symptoms.

Psychological Theories
Psychological

Testing shows:
Lack of creativity
Attention Deficits
Loss of Executive Functions

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. Because
the ego affects the interpretation of reality
and the control of inner drives, such as sex
and aggression, these ego functions are
impaired. Thus, 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. For example,
fantasies of the world coming to an end
may indicate a perception that a
person's internal world has broken
down.

Feelings

of inferiority are replaced

by delusions of grandeur and
omnipotence. Hallucinations may
be substitutes for a patient's
inability to deal with objective
reality and may represent inner
wishes or fears. Delusions, like
hallucinations, are regressive,
restitutive attempts to create a
new reality or to express hidden
fears or impulses.

Margaret

Mahler
There are distortions in the
reciprocal relationship between the
infant and the mother. The child is
unable to separate from, and
progress beyond, the closeness and
complete dependence that
characterize the mother-child
relationship in the oral phase of
development. As a result, the
person's identity never becomes
secure.

In

a study of British 4-year-old

children, those who had a 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.

Harry

Stack Sullivan viewed schizophrenia

as a disturbance in interpersonal
relatedness. The patient's massive anxiety
creates a sense of unrelatedness that is
transformed into parataxic distortions,
which are usually, but not always,
persecutory. To Sullivan, schizophrenia is
an adaptive method used to avoid panic,
terror, and disintegration of the sense of
self. The source of pathological anxiety
results from cumulative experiential
traumas during development.

Double-Bind

The

Communication

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.

In

Bateson's hypothesis, children withdraw

into a psychotic state to escape the
unsolvable confusion of the double bind.
Unfortunately, the family studies that were
conducted to validate the theory were
seriously flawed methodologically. An
example of a double bind is the parent who
tells the child to provide cookies for his or
her friends and then chastises the child for
giving away too many cookies to playmates.
No longer accepted.

Expressed

Emotion. Parents or other

caregivers may behave with overt
criticism, hostility, and
overinvolvement toward a person with
schizophrenia. Many studies have
indicated that in families with high
levels of expressed emotion, the relapse
rate for schizophrenia is high. The
assessment of expressed emotion
involves analyzing both what is said and
the manner in which it is said.

Learning

Theories
schizophrenia learn irrational
reactions and ways of thinking by
imitating parents who have their own
significant emotional problems.
poor interpersonal relationships of
persons with schizophrenia develop
because of poor models for learning
during childhood.

ROLE OF DRUGS
Amphetamines (agonists) lead to increase in
DA levels
Large quantities lead to delusions and
hallucinations

Substance

abuse
The lifetime prevalence of any drug
abuse (other than tobacco) is often
greater than 50 percent.
There has been particular interest in
the association between cannabis
and schizophrenia. Those reporting
high levels of cannabis use (more
than 50 occasions) were at sixfold
increased risk of schizophrenia
compared to nonusers.

The

use of amphetamines, cocaine,

and similar drugs should raise
particular concern because of their
marked ability to increase psychotic
symptoms.
In one population-based study, the
lifetime prevalence of alcohol within
schizophrenia was 40 percent.

Cultural and Socioeconomic

Factors

People

in developing countries are

less likely to develop
schizophrenia.

Clinical features

Mood disorders

Functional
disorders
Schizophrenia
spectrum
disorders

P
S
Y
C
H
O
S
I
S

Substanc
e
induced

organic
mental
disorders

Delirium
Dementia
Amnestic d/o

Key Features
Chronic syndrome
(negative symptoms)

Acute syndrome
(positive symptoms)
Hallucinations
Delusion
Disorganised
speech/thinking/
behaviour
Catatonic behaviours
Delusion of reference

Affective Flattening
Alogia
Avolition
Anhedonia
Attention(poor)

Positive symtoms
Those

that appear to reflect an excess or

distortion of normal functions. Positive
symptoms are those that have a positive
reaction from some treatment. In other
words, positive symptoms respond to
treatment.
Delusions. Those where the patient thinks
he is being followed or watched are
common; also the belief that people on
TV, radio are directing special messages to
him/her.

Hallucinations.

Distortions or
exaggerations of
perception in any of the
senses.
Often

they hear voices

within their own
thoughts followed by
visual hallucinations.

Disorganized

thinking/speech.
AKA

loose
associations;
speech is
tangential, loosely
associated or
incoherent enough
to impair
communication.

Grossly disorganized behavior.

Difficulty in goal directed behavior
(ADLs), unpredictable agitation or
silliness, social disinhibition, or
bizarre behavior.
There is a purposelessness to
behavior.

Inappropriate

response to stimuli
Unusual motor behavior (pacing,
rocking)
Depersonalization
Derealization
Somatic preoccupations

Catatonic
Marked

behavior.

decrease in reaction to
immediate environment, sometimes
just unaware of surroundings, rigid
or bizarre postures, aimless motor
activity.

Disorganized
Symptoms
This

one is
somewhat new and
may not be
considered valid.

It

is thought
disorder, confusion,
disorientation and
memory problems.

Negative Symptoms
Those

that appear to reflect a diminution

or loss of normal functions.

May

be difficult to evaluate because they

are not as grossly abnormal as positive
symptoms.
Currently there is no treatment that has a
consistent impact on negative symptoms

Affective

flattening.

Reduction

in the range and intensity

of emotional expression, including
facial expression, voice tone, eye
contact and body language.

Alogia

(poverty of speech)

Lessening

of speech fluency and

productivity, thought to reflect
slowing or blocked thoughts; often
manifested as short, empty replies to
questions.

Avolition
The

reduction, difficulty or
inability to initiate and persist in
goal-directed behavior. Often
mistaken for apparent disinterest.

No

longer interested in going

out with friends
No longer interested in activities
that the person used to show
enthusiasm
No longer interested in anything
Sitting in the house for hours or
days doing nothing

Cognitive Symptoms
Difficulties

in concentration and

memory:
Disorganized thinking
Slow thinking
Difficulty understanding
Poor concentration
Poor memory
Difficulty expressing thoughts
Difficulty integrating
thoughts, feelings, behaviors

Psychotic Disorders
Onset

Schizophrenia

Usually
insidious

Delusional
disorder
Brief
psychotic
disorder

Symptoms
Many

Course

Duration

Chronic

>6 months

Varies
Delusions
(usually
only
insidious)

Chronic

>1 mo.

Sudden

Limited

<1 mo.

Varies

Kurt Schneider (German psychiatrist)

s symptoms of first rank
1.

2.

3.
4.

5.
6.

Auditory hallucinations:
audible thought or thought
echo ; referring third person;
running commentary.
Alienation of thought:
thought insertion or
withdrawal
Diffusion of thought (thought
broadcasting)
Sensation of feelings, impulses
or acts being controlled by
external forces
Somatic passivity < external
agency (e.g. X-rays, hypnosis)
Delusional perception

MANAGEME
NTS

Course
20%

Complete recovery

20%

Recurrent acute illness

20%

Chronic disease
starting acutely

20%

Chronic disease
starting insidiously

1015%

Suicide

Prognosis
Recover

completely/long
term minimal symptoms30%(The percentage on
the rise)
Recurrent illness
-poorer prognosis
Young patient -high risk
of suicide

Predictors for poor outcome

Features of the
illness

Insidious onset
Long 1st episode
Previous psychiatric history
Negative symptoms
Younger age at onset

Features of the
patient

Male
Single, separated, widowed or
divorced
Poor psychosexual adjustment
Poor employment
Social isolation
Poor compliance

Assessment
No

confirmatory laboratory
studies.
Diagnosis made based on
psychotic symptoms and
functional deterioration.
Diagnostic evaluation: aim

Establish the presense of

psychosis
Eliminate other differential
diagnosis

Evaluation of of psychosis

ALGORITHM FOR MANAGEMENT OF SCHIZOPHRENIA

Diagnosis of
Schizophrenia

Identify Phases of Illness

Acute
phase

Need rapid
tranquilisati
on

No

Yes

Urge
nt
No

Combination of
parenteral treatment

Yes

Oral medication is preferred

When parenteral needed, use a single agent

Provide comprehensive plan (pharmacological, psychosocial & service level interventions)

Offer conventional APs (300-1000mg CPZ equivalent) or AMS or OLZ
Monitor clinical response, side effects & treatment adherence

Poor
response

Yes

No

Relapse
prevention

Stable
phase

Adequate
dose &
duration
No

Yes

Exclude substance abuse, treatment

non-adherence & concurrent other
general medical conditions
Optimise psychosocial interventions
Refer to psychiatrist for trial of
clozapine

Optimise APs usage

Plan for recovery (ACT, family intervention, psychoeducation, social skills training & supported employment)
APs usage to continue with single oral agent from acute phase; use depot when non-adherent
Monitor for clinical response, side effects & treatment adherence
Follow-up at primary care
Follow manual on Garispanduan
Perkhidmatan Rawatan Susulan
Pesakit Mental di Klinik Kesihatan

Prevention & management of side effects of APs at all phases

aonitor EPS/akathisia/weight gain/diabetes/heart
disease/sexual dysfunction
105
Follow schedule of physical care as per follow-up manual

THREE PHASES OF SCHIZOPHRENIA

Prodromal
Decline in
functioning that
precedes 1st
psychotic
episode
Socially
withdrawn,
irritable
Physical
complaints
Newfound
interest in
religion / the
occult

Psychotic
(acute
phase)
Positive
symptoms
Perceptual
disturbances
(e.g. auditory
hallucinations)
Delusions
(usually
secondary,
delusion of
reference
common)
Disordered
thought
process /
content

Residual
(chronic
phase)
Occurs between
episodes of
psychosis
Marked by
negative
symptoms (flat
affect, social
withdrawal)
odd thinking
and behaviour

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