Schizophrenia and Associated Psychoses    Schizophrenia: Introduction: Of all the psychiatric predicament, schizophrenia is the most difficult to define and describe. Over the last 100 years extensively divergent concepts have been held in unique countries and by different psychiatrists. Essential concepts are (over easy) Acute schizophrenia (Type 1): Predominated by way of positive symptoms such as delusions, hallucinations as well as interference with thinking. Good prognosis Chronic schizophrenia (Type II): Negative symptoms: apathy, lack of drive (diminished volition), slowness and social withdrawal. Poor prognosis. Recent reports proposed more complex delineations correlating to cerebral as well as psychological symptoms Reality disruption: delusions and hallucinations, left medial temporary lobe and cingulated cortex. Disorder of personal monitoring. Disorganization: Formal idea disorder, inappropriate affect, peculiar behaviour, anterior cingulated, right ventral frontal cortex, bilateral parietal regions. Disorder of selective particular attention (suppression). Psychomotor poverty: Flat impact, poverty of speech, lessened spontaneous movement, under action of pre-frontal cortex. Disorder of term generation and planning (initiation) Other aspect of the clinical syndrome:  Depressive symptoms: may perhaps be part of the syndrome, post psychotic point or side-effect of the antipsychotic.   Cognitive attributes: impairment in learning, memory plus attention.   Neurological signs: consequently cold soft signs. Problem in sensory integration, dexterity, and catatonic features.   Olfactory dysfunction: affecting the identification, sensitivity as well as memory for odours normally worse in the left nostril. Medically may contribute to lack of societal drive.   Water intoxication: within few chronic patient drinking water intoxication characterized by polyuria and hyponatraemia. Might point to hypothalamic regulation abnormality esp. related to antidiuretic endocrine. Diagnosis: ICD-10: At least one clear warning sign (similar to Schneider’s first rank signs i.e. break down with self boundary) a. Idea echo, insertion, withdrawal, transmitted b. Delusions of control (passivity), delusional conception c. Voices discussing inside third person, running commentary, voices from some section of the body. d. Other prolonged delusions that are completely impossible Or even at lease 2 signs and symptoms: a. Persistent hallucinations ± delusions (e.gary the gadget guy. persecutory, reference, religious etc). w. Formal thought disorders (trip of ideas, perseveration, loosening associated with association, widening of thought) c. Catatonic behaviour e.g. posturing, stupor d. Negative symptoms electronic. Change in overall quality of personal behaviour Illness for A month (DSM-IV 6 months). Sub types: Paranoid: stable delusions and usually hallucinations Hebephrenic: formal imagined disorder, inappropriate affect, peculiar behaviour, fleeting delusions and hallucinations, certain illness. Catatonic: motor symptoms predominate Undifferentiated Residual: chronic stage, predominantly bad symptoms Simple: only bad symptoms Post-schizophrenic depression Other schizophrenia Unspecified schizophrenia  (Around DSM-IV: Paranoid, Disorganised, Catatonic, Undifferentiated, Residual) Differences between the ICD-10 and DSM-IV): ICD-10 places greater excess fat on first rank signs ICD 10 requires 1 month versus. 6 month in DSM-IV ICD 10 has got more additional sub-types Disorganised in DSM-IV known as Hebephrenic in ICD-10. Duration in DSM-IV: 1 day one monthà Brief Psychotic Disorder 1 month to 6 monthsà Schizophreniform Disorder More than 6 month à Schizophrenia Differential Conclusions Organic syndromes “Organic Psychosis” ( as opposed to so called Functional psychosis for example schizophrenia) e.g. TLE, carcinomas, CVA, AIDS, CJD, Company Poisoning, Fahr’s disease, Huntington’s, Syphilis, Wilson’s and many others. (ALWAYS EXCLUDE ORGANICITY/MEDICAL CAUSES!!) Drug induced psychosis Ambiance disorders with Psychotic Features Delusional Ailments Personality Disorders Epidemiology of Schizophrenia Life risk 1% Incidence: 0.Your five per 1000 Prevalence: Three per 1000 Median period of onset: M=28 yr, Females 34 yr (but anywhere between 12-15 to 55) Gender M=F (early is more common in males, late (Paraphrenia) is more common in Females) Better rate in urban when compared with rural areas Higher pace in immigrant Aetiology Very complex, debatable, however the whole range of  biological, mental and social factors are needed. Genes: e.g. Neuregulin, Dysbindin Enviromentally friendly: Obstetric complications, maternal influenza, wintertime birth, early cannabis utilize, paternal age. Social: Migration, urban birth and upbringing, recent lifetime events Structural :smaller mind size, reduced synaptic markers Sensible imaging: Hypofrontality Neurophysiological: Abnormal eye following, Abnormal esenory evoked potential Neurochemical: Dopamine, Glutamate Psychological: cognitive impairment, personality factors, psychodynamic concepts, family dynamic and sales and marketing communications Main hypothesis are the Neurodevelopmental (The pathological adjustments are laid down at the beginning of life, presumably through genetic influences and then modified simply by maturational and environmental factors), aberrant online connectivity, Stress-vulnerability. Key aspect of the present agreement regarding the aetiology are summarised as follows: An important influence is genetic, approximately 80% of the risk being ancestral. The mode of bequest is complex and the body’s genes, some of which have been recently acknowledged, act as a risk point, not determinant of illness. A number of environmental factors contribute way too, many of which appear to act prenatally, as well as which interact with the innate predisposition. Together these plus subsequent risk factors produce neurodevelopmental disturbance which either leads to, or renders the individual prone to,, the later emergence involving symptoms, and which shows itself premorbidly in a range of behavioural, intellectual and neuroanatomical features. Inside schizophrenia, the brain is slightly smaller than usual, and there are localized variations in its structure and performance, leading to the view that the syndrome is a disorder of online connectivity within and between brain regions. Acute psychosis is associated with too much dopamine, whereas the persistent cognitive impairment may result from lacking dopamine function in the prefrontal cortex, both probably secondary to abnormality to your glutamate system. Course and prediction Generally agreed that the outcome of schizophrenia is worse than that of a lot of psychiatric disorders, however, prediction may not be as bad as in the past thought!  After 13 years post disaster: 15-20% of first episodes will likely not recur 50% are without psychotic signs or symptoms 50% are without negative signs or symptoms 55% show good social performance. Mortality and morbidity is much very high population and suicide up to 10%. Good prognostic Factors: Sudden onset Shorter episode No previous mental history Prominent affective warning signs Paranoid type Older age of onset Married Good psychosexual adjustment Good premorbid personality Good work file Good social relationships Excellent compliance. Normal brain morphology (e.g. normal ventricles)  Factors’ acting as soon as the illness has been established Societal background: incidence is similar in different countries but the course in addition to outcome is different, studies report that patient in developing nations have favourable course in comparison to developed ones (after engine performance). Life events (stress) Social stimulation: under stimulation connected with worsening of the negative signs and symptoms and over stimulation with deterioration of the positive symptoms. Societal background and belief Expressed Feelings (hostility, criticism, emotional around involvement) extremely important cause for backslide. Patient living in families rich in level of E.E have 2 to 3 times increased risk of relapse. Management and treatment: History MSE Physical Examination Examination (physical and psychological) Treatment: v Pharmacological Antipsychotic Drugs: 1. Conventional antipsychotics: Chlorpromazine, Thioridazine, Haloperidol (all behave to reduce dopamine levels) Side effects:   EPSE (extrapyramidal negative effects) -Acute Dystonia: contraction of muscles to help maximal limit, typically sternocleidomastoid plus tongue, although can be extensive (e.g. opisthoclonus); eye muscle groups involvement (oculogyric crises) may appear. Very distressing. Treatment along with procyclidine i.v -Parkinsonism: tremor, rigidity and bradykinesia occurring >1 week after everyone. Consider dose reduction or procyclidine oral. -Akathisia: restlessness, usually of lower limbs, and push to move. Occurs usually > 1 month after treatment. BDZ and propranolol used for treatment. Often goes undiscovered. Associated with risk of violence and also suicide. -Tardive dyskinesia: continuous slow writhing motions and sudden involuntary moves, typically of the oral area. Symptoms tend to be irreversible (the older the patient the more likely). Treatment solutions are difficult, procyclidine worsen the condition or maybe reduction of the antipsychotic can make it worse. Vit E may prevent degeneration. Anticholinergic side-effects: Dry mouth, blurred vision, problems passing urine, urinary retention, irregularity, glaucoma, confusion, cognitive impairment. Antiadrenergic side-effect: Postural hypotension, tachycardia, erectile dysfunction. Antihistaminic side-effect: Sedation, weight gain Hyperprolactinemia. Cardiovascular chance: prolongation of QTc interval, sudden death (Pimozide)  Idiosyncratic: Cholestatic jaundice, altered glucose tolerance, hypersensitivity reaction, skin photosensitivity, yellow skin discoloration of the skin, Neuroleptic Malignant Syndrome (hardness, fluctuating consciousness, and pyrexia. Could be fatal , requires ICU admission).  2.More modern antipsychotic (so called atypical):  e.g. Olanzapine, Quetiapine, Resperidone, Ziprasidone and many others.  Safer versus the ‘older generation’. Very expensive. Not devoted of significant side effect, depends on the agent. Recently linked to causing DM as well as hypercholesterolemia. In high doses (and several times within normal serving, could have similar side effect when typical antipsychotic). Other side effect depends on the drug e.f. Olanzapineà weight gain. All antipsychotics (typical and also atypical) have similar clinical effect. None is superior technically. The exception is Clozapine (merely agent licensed for resilient schizophrenia). Need continuous blood checking, weekly for 18 h and then regularly (depends on which in turn guidelines). Risk of agranulocytosis and neutropenia.   Psychosocial technique: Effective psychosocial interventions include: Family Therapy Mental behavioural therapy Social abilities training Social support Illness management techniques Assertive community treatment. Delusional Problem: The patient present with circumscribed signs and symptoms of non-bizarre delusions, but with absence of prominent hallucinations without thought disorder or ambiance disorder. Symptoms should have been recently present for at least 1 month from the DSM-IV and 3 months in The ICD-10. Relatively uncommon (0.03% ), but be the reason for up to 2% of hospital entrance Sub-types: Erotomania (Delusion of Love/ de Clérambault Malady) Patient present with the notion that some important person is secretly in love with them. Healthcare samples are often females and also forensic samples often males. Client may make efforts to contact those, and some cases are related to dangerous or assaultive behaviour. Harassment. Grandiose Patient believes that they fill some special role, incorporate some special relationship, or incorporate some special ability. They may be included in social or religious enterprises. Jealous (morbid jealousy/ Othello syndrome) Patient possesses the fixed thinking that their spouse or perhaps partner has been unfaithful. Usually patient try to collect evidence or attempt to restrict his or her partner’s activities. This type of delusional dysfunction has been associated with forensic cases affecting murder. Persecutory This is the most common type. Patient are convinced that others are trying to do them harm. Normally they obtain legal recourse, and they sometimes may use violence. Somatic Varying presentation, out of those who have repeat contact with health professionals requesting various forms of professional medical or surgical treatment to people who are concerned with bodily pests, or deformity (dysmorphophobia), or smell Induced or shared delusional ailments (Folie a deux/ Communicated insanity) Your paranoid delusional system which appears to be have developed in a person due to a close relationship with another person exactly who already has an established delusions. Could be more than one person (e.g. a family, ‘cult’). 90% of cases usually are members of same family, principal partner and isolated. F>M. often separation improve the recipient but is not the inducer. Subtypes: Folie imposée: primary psychotic illness in a single adopted by another Folie simultanée: most important psychotic illness in both with similar delusions Folie communiqué: primary psychotic illness in both during different times with delusions shared or passed on. Folie induite: pre-existing primary psychosis within a patient, adopts fellow person’s delusions. Delusional misidentifications syndromes: ?Capgras delusions: The patient believes others have been replaced by identical or near identical impostors. Can apply for you to animals and other objects, and often associated with aggressive behaviour ?Fregoli delusions: Affected person identifies a familiar person (usually his persecutor) in various other people he encounters (psychologically simply). ?Intermetamorphosis syndrome: The patient believes they are able to see others change into another individual (both external and internal appearance). Bodily and psychologically   ?Subjective doubles delusions (Doppelganger): The individual believes there is a double which exist and functions independently   ?Reversed subjective double syndrome: The patient believes that that they are an impostor in the process to become physically and psychologically supplanted. Autoscopic syndrome: The patient sees your double of themselves projected onto other people or physical objects nearby       References: 1. Stevens L, Rodin I, Psychiatry: An illustrated coloration text, Churchill Livingstone 2001 2. Steple N. Oxford Handbook of Psychiatry, Oxford University Touch, 2006 3. World Wellbeing Organisation (WHO): ICD10 Classification regarding Mental and Behavioural Ailments (1992) 4. American Mental Association. The Diagnostic and also statistical Manual of Mental Disorders (DSM-IV).1994