(1) INTRODUCTION IN PSYCHIATRY

Competences: To understand object and limitations of psychiatry as medical discipline,

definition, history, epidemiology.

Psychiatry
Greek etymology
Psyche =soul
Iatrea =cure
Medical discipline
The study of psychiatric disorders
Medical assistance of the patients
Disorder versus disease
Distortions of personality
Changes of conscience
Changes of relationship with external medium

Psychiatry a complex medical discipline
Human personality functions:
Biological
Psychological
Axiological
Social
Cultural
Relationship with other medical disciplines
Morfology
Fiziology
Biology
Genetic
Neurology
Endocrinologie
Internal medicine
Psihology
Sociology
Antropology

Burden of psychiatry
To prevent psychiatric disorders and to promote mental health
Decrease of morbidity-diagnose and early treatment of the patients
Recovery, reintegration and resocialization of the patients
Education for young doctors
Scientifically research

Historical Issues

Before Hipocrates period:
- A period of ignorance and superstition (Regis)
- Supernatural forces determine psychiatric illness
- King Saul -developed manic and depressive episodes along lifetime
- Licantropia of Nabucodonosorhe had delusional thoughts that he will be
transform into a wolf
- Paricid of Oreste, epilepsy of Hercule, violence moments of Achile etc.
- Temple of Esculap persons who treated psychiatric disorders using religious
ceremonies, a form of psihoterapy, kinetoterapy, meloterapy

Hipocratic period:
- Hippocrate considered that psychiatric disorders are diseases of the brain and the
patients must be treated by the doctors and not by the priests
- He described clinical aspects of phrenitis(acute fever delirium), mania,
hipocondriac delusional thoughts, alcholic delirium,epileptic psychosis, hysteria
- He treated psychiatric disorders using drugs like elebor and mandragora
- Herophyl i Erasistrat(300b.Ch)-they continued ideas of Hipocrate about
psychiatric disorders

Medium eve
Arabian concepts
Avicena published a book about melancholy
Ahmed Ibu Aljazzar published a book about love ill
European concepts in opposite with Arabian concepts about psychiatric disorders
Obscurantisme medical issues was influenced by religious concepts
Demonomanii-the devil come into the body of the patient and will
determine epilepsy
Persecutions and death condemnations for persons with psychiatric
disorders
Bedlam in England (sec. XVI) was a settlement for patients with psychiatric
disorders, where they stayed without heat or bed;
Petite Maison in France-the patients were exposed in public and they did not have
any condition in this settlement

Modern period
Ph. Pinel (1772) new approaches of treatment for psychiatric patients
Esquirol described clinical aspects of monomanie and dementia
Lasegue - described persecutory delusional thoughts
Falret described folie a deux
Baillarger described folie circulaire and folie a double forme (manic and
depressive episodes)
Magnan considered that clinical observation had a great role in psychiatry
- discovered the concept of psychopathy
Griesinger psychiatric disorder represents a disease of the functioning of the
brain; he considered that there area certain connections between psychiatry and
neurology
Russia (sec. XVIII, XIX) Balinski-conduced the first department of psychiatry
at Medico-Surgery Academy;
- Kandinski- realized the first classification in psychiatry and described
pseudohallucinations;
- Secenov-papers about reflex of the brain;
- Korsakov-described alcoholic psychosis.
Kraepelin-he realized boundaries and classifications of the entities of psychiatry
(introduced the concept of nosology in psychiatry)
Ribot - studied disorders of the memory
Charcot described hysteria
Freud
Bleuler
Meynert-described amentia,
Wernicke- described presbiofrenia, alcoholic halucinosis,
Kleist-described involution paranoia

Social Psychiatry And Development Of Psychiatric Assistance In Romania
Feudal periode - medical assistance in psychiatry was realized in some
monasteries:
Cldruani, Schitul Balamuci, Mrcua in Muntenia
Schit Madona Ducu in Oltenia
Neam, Golia in Moldova
Matei Basarab 1652- in pravile described legal aspects about assistance of
psychiatric patients
Al. uu(1837-1919)- founder of Romanian school of psychiatry
Al. Obreja realized a modern assistance for psychiatric patients, defined
ciclofrenia (schizophrenia)
Iasi- in 1881, Golia became a base from psychiatric and neurological medical
education
Julien Lucacevski-preoccupied of epidemiology, therapy and especially
ergotherapy; 1883-1894- conduced Golia hospice
Al. Brescu-1895-course of pathology of mental disorders

Socola hospital
1905
Al. Brescu
C.I. Parhon
L. Ballif
P. Brnzei
T. Pirozynski
P. Boiteanu


Conceptions and new approaches in psychiatry
Organogenetic hypothesis(Griesinger)-psychiatric disorders are explained by
cerebral lesions
Psihogenetic hypothesis -psychiatric disorders are determined by some difficulties
during lifetime
Organodinamism any psychiatric disorder involved an organic lesion
undiscovered yet
Psihanalize human psychic was determined by an inconscience motivation;
Freud- the essence of inconscience is represented by the sexual instinct
Fenomenology (Jaspers) conserved the authenticity of psychopathological
manifestations by expressing all the feelings of the patients
Existentialism-the main important thing for understanding psychiatric disorders is
the human being and medical empathy
Psihosomatic stress can determine somatic illness
Pavlovism psychiatric disorders are determined by biochemical changes and
cerebral lesions
Social Psihiatry
Transcultural Psihiatry a psychiatry in which we observed some characteristics
of psychiatric disorders from cultural aspects
Antipsihiatry (Cooper)- psychiatry is not a medical science

New approaches in psychiatry
clinico-nosologic direction (Kraepelin)- classification of psychiatric disorders
using clinico-nosological criterion, psychiatry become a medical science
clinico-statistic direction- created boundaries of syndromes, nosological entities
and created correlations between terminology from different psychiatric schools
psihosocial direction the role of psychiatrists become more complex and
involve prophylaxis of psychiatric disorders and social recovering and
reintegration of the patients



(2) PSYCHIATRIC SEMIOLOGY

Competences: To know theoretical aspects about psychiatric interview and to evaluate
cognitive function (to realize mental status examination)

Psychiatric Comprehensive Mental Status Evaluation
Observations
Psychiatric Interview

a) Observations
Dress (disheveled, eccentric, flamboyant, unilateral neglect)
Demeanor (anxious, impulsive, apathetic)
Social interaction (suspicious, unduly familiar, distractible, excessive
dependence on spouse)
Mood (jocular, sad, irritable, angry, labile, perplexed)
Speech (mutism, stutter, dysarthria, abnormal volume, disturbed speed)
Language (fluent aphasia, nonfluent aphasia, echolalia, palilalia, coprolalia)
Motor behavior (compulsions, absence spells, stereotypies, movement disorder,
hyperactivity, gait abnormalities)
Psychomotor speed (slow, rapid)

b) Psychiatric Interview
- Mood (happy, sad, labile, anxious)

- Thought form
Thought disorder (tangential, circumstantial, loose associations, illogicality,
derailment, flight of ideas)
Perseverations and intrusions (abnormal persistence or recurrence of ideas,
words, etc.)
Incoherence

- Thought content
Delusions
Hallucinations (visual, audi1tory, tactile, gustatory, olfactory, somatic)
Obsessions (involuntary intrusive ideas)
Depersonalization, derealization

Psychodiagnosis of expression
Attitude
Appearance (Dress)
Behavior
- facial expression
- tone of the voice
- pantomimic
- look

Appearance (dress)
Eccentric
Exaggerate
Bizarre
Disorderly
Cisvestitism- improper for a certain age and situation

Pantomimic-qualitative changes
Mimic involuntary and reflex non-verbal expression
Hypermimia- exacerbation of the mimic
Hypomimia diminished of the mimic
Amimia- immobility
Paramimia a mimic inconsistence with psychic state
Ecomimia- imitation of the other persons mimic
Hemimimia unilateral motion
Neomimia bizarre mimic
Jargonomimia multiple, misunderstood and bizarre pantomimic
Psitacism mimic increasing mobility, featureless
Parakinezia the movements lost their sense and natural or logic condition
Mannerisms exacerbation of manners
Abnormity lost of logical expressiveness of the movements or gestures
Stereotypes- pathological repetition of the same bizarre motor conduit
akinetic (attitudinal)
- parakinetic (movement)

Activity
psychomotor agitation- extreme manifestation of psychomotor excitation(
hyperkinesias with restlessness and disorganization of motor activities)
Hypokinesias reduced of psychomotor activity
Hyperkinesias exacerbation of psychomotor activity
akatisia- the patient is restlessness and needs to pace continuously
stupor complete immobility, without any response to any external stimuli
catalepsy- total motor inertia
tics involuntary movements, the patient is aware of them

Sensation And Perception

a) Quantitative changes of sensation
Sensation simple psychic function which represents a form of projection of
characteristics of the objects from around
Hyperesthesia-decreasing of sensation's threshold
Hypoesthesia- increasing of sensation's threshold
Cenestopaty diffuse sensation, without a certain localization and without an
organic disorder


b) Qualitative changes of perception
Perception-complex psychic function which realizes the knowledge of reality by
analyze and synthesis of sensations
Hallucinations are perceptions that occurs in the absence of actual stimuli
Illusions are misinterpretations of existing stimuli
Agnosia-illusions of gnosis integration, incapacity of recognize objects using
their characteristics

HALLUCINATIONS
They are sensory perceptions occurring without appropriate external stimulation
of the relevant sensory organ
Hallucinations may occur in any sensory modality


Differential Diagnosis of Visual Hallucinations




Hallucinations
Mistakenly and repeatedly hearing, feeling, smelling or seeing things that are not heard,
felt, smelled, or seen by other people
Condition/Lesion Location Cause
Ocular abnormality Enucleation
Cataracts
Macular degeneration
Vitreous traction

Optic nerve abnormality Optic neuritis (ischemic, demyelinating, glaucoma)

Brainstem abnormality Peduncular hallucinosis (infarction, tumor)

Cerebral hemispheric lesions Geniculocalcarine lesions (infarction, tumor)

Neurological illnesses Migraine
Epilepsy
Narcolepsy

Medical illnesses Delirium
Toxic disorders Delirium
Withdrawal
Hallucinogens

Psychiatric disorders Schizophrenia
Mania
Depression

"Normal" conditions Hypnagogic hallucinations
Imaginary companions of childhood
Sensory deprivation, Sleep deprivation


Psychosensorial hallucinations
Exteroceptive-auditory, visual, gustative, olfactive, tactile
Interoceptive
Proprioceptive

Functional hallucinations-perception during the existence of a real stimuli
Eidetic hallucinations - hipnagogic, hipnapompic- false perception at the moment
of falling asleep or at awakens
Halucinosis-the patient recognizes the false perception and has a critical attitude
Pseudohallucinations - aperceptive perception, without a spatial projection,
automatism

Schneiderian first-rank symptoms
delusional experiences
hearing one's thoughts spoken aloud
hearing voices arguing about oneself
hearing voices commenting on one's actions
having bodily sensations imposed from outside
attributing one's feelings to external sources
experiencing one's drive and actions as controlled from the outside
having one's thoughts inserted or withdrawn from the mind
broadcasting one's thoughts, and attributing special delusional significance to
one's perceptions
most common in schizophrenia
schizophrenia/like manifestations - epilepsy, Huntington's disease, and idiopathic
basal ganglia calcification.

Alertness
The drowsy patient is fatigued and falls asleep when unstimulated.
Obtundation is a state of moderately reduced alertness with slow responses and
diminished interest in the environment.
Stupor is the next most severe level of impaired consciousness. Stuporous
patients must be vigorously stimulated to be aroused and engaged in conversation.
Stupor returns when stimulation ceases.
Coma is state of unarousable unresponsiveness.

Attention (prosexia)
Kraepelin Test - count backward from 100 by 7s
spelling words backwards
Complex psychic process which it is realized by orientation and concentration of
psychic system to objects and phenomenon
Hiperprosexia- increased of selective orientation of cognitive activity
Hipoprosexia- reduced of selective orientation of cognitive activity
Aprosexie- absence of all possibilities of prosexia

Memory
A psychic process realized by fixation, keeping and evocation of known information
from past experience
learning, recall, recognition, and memory for remote information
the patient is given three words to remember and then is asked to recall them 3
minutes later
dates of marriage, birth dates of children

a) Quantitative changes:
- Hipermnesia - increased of evocation (multiple, involuntary, the person is
kept away from main preoccupation)
- Hipomnesia - decreased of evocation
- Amnesia - loss of any capacity of evocation
anterograde
retrograde
antero-retrograde
temporary-partial or total
elective
later

b) Qualitative changes
Changes of immediate and recent memory=illusions of memory-false
evocation of some actions or phenomenon, lived by the patient, but with a
wrong frame in time and space
- Criptomnesia- the person didn't make the difference between their
memories and the memories of others
- False identification- to recognize something that it is not recognized
- Illusion of unrecognized the patient believes that can recognize an
unknown person and can not recognize known person
- Paramnesia of reduplication- permanent halving of lived situations

Changes of long term memory (allomnesia)
Pseudoreminescences the patient lives in the present some events from
the past
Confabulation the patient presents some imaginative events like there
were in his past
Ecmnesia- the patient lives in the present all the events from the past
Anecphoria the possibilities to remember some events from the past,
which the patient believed forgotten

Thought
A generalized and mediate complex cognitive activity by which it can be distingue the
essential from the phenomenal using experience and processing of information

a) Changes of rhythm and coherence of the thoughts
Tahipsihia - quasi-total increasing of the psychic life
Flights of ideas - increased the rhythm of the thoughts
Word salad - an incoherent collection of words and phrases
Verbigeration - convey little information despite adequate volume of speech due
to vagueness, empty repetitions or obscure phrases
Bradipsihia - reduced the rhythm of the thoughts
mental fading- increasing of slowness of the thoughts till they stop
Barrage of the thoughts -the thoughts are stopped suddenly for a few seconds,
after that the thoughts come back
Anideation - absence of any thoughts
incoherence of the thoughts- extreme exacerbation of flights of ideas, lost of all
formal logical relationship of associations
Mentism - incoercible increasing of thoughts and representations, the patients has
critical attitude, but usually they can not stop their thoughts
b) Changes of the content of the thoughts
Dominant thoughts- an idea different from other ideas, which it is imposed in a
moment of the thinking, reversible idea
Obsessions- recurrent, intrusive thoughts, images or impulses that are ego-
dystonic and involuntary
compulsionsrepetitive, stereotyped behaviors
Prevalent thoughts - an idea which it is dominant on the field of conscience,
inconsistence with reality, the other ideas sustained it and it changes the normal
course of the thoughts
-hypochondria obsessions or prevalent thoughts focus on function of the body,
which could have a disease
Delusions are fixed, false beliefs that have no basis in reality, are not held by
one's culture and from witch the patient will not be dissuaded despite evidence to
the contrary

DELUSI ONS
false beliefs held despite evidence to the contrary
delusions are not reactions to declining intellectual function
no specific neuropsychological correlates of delusions (e.g., deficits in memory,
language, visuospatial functions, frontal lobe abilities) have been consistently
identified
there is no delusional content that distinguishes neurological illnesses from
idiopathic psychotic processes such as schizophrenia
visual hallucinations are more common in conjunction with delusions in
neurological illness than with idiopathic psychoses
delusions are most common in diseases affecting both hemispheres
delusions are not invariably linked to lesions in specific anatomical structures
it is common for the onset of delusions to be delayed for considerable periods
after the occurrence of a brain insult
delusions may respond to neuroleptic agents and rarely improve with
anticonvulsants or other nonneuroleptic medications

Content Specific Delusions Observed in Neuropsychiatric Disorders
Delusional incubus or succubus: demon or phantom sits on top of or has sex with
the individual during sleep
Intermetamorphosis: familiar persons takes on the appearance of tormentors
Lycanthropy (werewolfism): the individual periodically turns into an animal
Jealous (Othello syndrome): the individual's spouse is unfaithful
Parasitosis: the individual is infested with insects, worms, lice, vermin
Delusional phantom boarder: unwelcome guests are living in the individual's
home
Capgras's syndrome: a significant other (usually a family member) has been
replaced by an identical-appearing imposter
Erotomanic (de Clerambault's syndrome): the individual is secretly loved by
another, usually someone of higher social or economic status
Dorian Gray: others are aging while the individual appears to remain the same
age
Persecutory (Fregoli's phenomenon): a persecutor is able to assume the
appearance of others
Doppelganger: the individual has a twin or second self

Obsessions
recurrent, intrusive thoughts, images, or impulses that are ego-dystonic and
involuntary
compulsionsrepetitive, stereotyped behaviors
Obsessive-compulsive Disorder


Disorders Of The Language

Dyslogia it is a consequence of the changes of form and content of the thoughts
Dysphasia disorder regarding understanding and expression of writing or
speaking language
Dyslalia disorder of pronunciation

a) Dyslogia Changes of the form of verbal activity
Increased of verbal activity
Logorrhea
Tahiphemie
Bradiphemia verbal hypoactivity
Mutisme absence of communication
Mutitate impossibility to speak
Musitate whispering speech
Mutacisme deliberate absence of speaking
Aphemia absence of communication with interruption which expressed
negation, thanks or eagerness
Echolalia-repetitive, often playful repetition of the words of others
Palilalia involuntary repetition of the words
Onomatomania obsessive repetition of the words, especially rudely words
Psitacisme mechanic sound of the words

Dyslogia Changes of the semantic and linguistic content
Neologisms made-up words that have meaning only for the patient
Glosolalia frequent using of the neologisms with a specific accent
Agramatisme telegraphic speak
Paragramatisme bizarre expressions
Embololalia normal speak with foreign words




b) Dysphasia
Verbal deaf can not understand speaking words
Intoxication by words repetition of the answer at a question, also at the next
question
Verbal amnesia to forget some words, the vocabulary
Alexia can not understand writing words

c) Dyslalia
Rotacisme difficulties of pronunciation of R
Sigmatisme - difficulties of pronunciation of S, Z, Y, ps, ts, ks
Rinolalie nosing speaking (nasal dyslalia)
Balbisme
Clonic repetition of the syllables from the beginning of the word
Tonic resistance to pronounce a word and after that a sudden expulsion

Changes on graphic flux
Changes of graphic activity
Graphorea increased of graphic activity
Decreased of graphic activity till refused to write
Graphomania exacerbation of graphic expression
Incoherence any relationship between words or phrases
Stereotypes repetition of some words or phrases
Changes of graphic morphology
Griphonaj the writing can not be read
The writing in the mirror- writing from right to left
Changes of graphic semantic
Paragraphisme transposition of the words or letters
Neographisme corresponding to neologisms


IMAGINATION
A psychic process by which it is created images using processing, transformation and
synthesis of representations or ideas

Changes of imagination
Increasing of intensity
Decreasing of intensity
Mitomania exaltation of imagination, characterized by romances organization
of livings, existential alibi, overmeaning and fear
Confabulation
Simulation falsification of the truth regarding the health
Metasimulation the patient preserves on their accuses after a pathological
situation
Suprasimulation amplification of a preexisting disorder
Disimulation hiding the disease

(3) PSYCHIATRIC SEMIOLOGY

Competences: To evaluate all psychiatric functions and to know all the test needed for
diagnosis

Affectivity
Subjective feeling regarding self and ambiance which are expressed by
reactions(emotions), feelings, attitudes
Instinct complex innate reflex which it has a biological and vital meaning
Emotions particular states which expressed an affective response of the
relationship between subject and objects, phenomenon or other persons
Mood general affective state with long duration and medium intensity which
reflects functional state of the body and represents the result of extero, intero and
proprioceptive impulses and it is conscience or not
Feelings complex, stabile, general emotional state
Passions - compare with feelings are a greater amplitude, more stable regarding
the relationship with ambiance


MOOD

Quantitative changes of the mood
Hipertimia-positive pole (euphoria,mania)
Hipertimia negative pole (depression)-intense affective implication with moral
pain, inutility and devalorization
Hipotimia-decreased of affective tension till apathy and indifference
Atimia marked decreased of affective tonus and of capacity to resonance to
external stimuli

Depression
Grief for lost object
Grief for lost function, altered role and status, and increased dependence
Without reason
Depressive mood
Feelings of sadness, worthlessness, hopelessness
Insomnia or hipersomnia
Anxiety or inhibition
Recurrent thoughts of death or suicide
Lost appetite
Lack of interest and pleasure

Mania
less common than depression
structural lesions producing mania usually involve the basotemporal region,
parathalamic structures, or the inferior medial frontal lobe
Euphoria
Disinhibition
Involvement in many activities
Decreased need for sleep
Logorrhea
Flights of ideas

Anxiety
a state of apprehension, tension, or uneasiness that occurs in anticipation of
internal or external danger
includes motor tension, autonomic hyperactivity, apprehensive expectation, and
heightened vigilance
Neurosis, depression, schizophrenia etc.

Qualitative changes of the mood Paratimia
aberrant and inadequate, even paradox, affective reactions regarding situations
or events
Inversion of affection affective reaction, negative one, toward the persons who
was loved before the onset of the disorder
Ambivalence- coexistence of qualitative opposite affective states toward the same
person


PARAPHILIAS AND ALTERED SEXUAL DRIVE

Quantitative changes of sexual instinct
hypersexuality increased of sexual instinct- nymphomania (woman), satyriasis
(man)
Hiposexuality decreased of libido

Altered Sexual Drive
Exhibitionism to expose genital organs in public
Fetishism sexual satisfaction using objects of opposite sex
Pedophilia - sexual act with children
sexual masochism sexual satisfaction is determined by pain
sexual sadism the person determines pain to the partner and thus obtains sexual
satisfaction
pygmalionism masturbation or sexual satisfaction in front of the statues
bestiality (zoophiles)- sexual act with animals or birds
Necrophilia sexual act with corpse
Gerontophilia sexual act with very old persons
Pedophilia sexual act with children
Masturbation erotic autosatisfaction
Homosexuality sexual act with persons of the same sex-lesbianism (women),
pederasty (men)


CHANGES OF ALIMENTARY INSTINCT
Bulimia- increased need of food
Polifagia ingestion without any restriction of food or other objects
Anorexia decreased alimentary appetite
Sitiophobia refused to eat on a psychotic context

CHANGES OF DEFENSE INSTINCT
Increased the necessity of auto conservation- hypochondria
Decreased or absence of defense instinct suicidal attempt, automutilation

Ganser's Syndrome
a manifestation of malingering, confusional state, or disinhibition syndromes
raise suspicion of duplicity
" five quarters in a dollar, 13 months in one year."


WILL (VOLITION)
a process which realizes the orientation of the psychic activities to a certain goal
and it is elaborated operations and activities to overtake all the subjective or
external resistances

a) Quantitative changes of the will
Hiperbulia- exacerbation of volitional force
Hipobulia decreased of volitional force
Abulia absence of initiative and capacity of action

b) Qualitative changes of the will
Disabulia difficulties to begin or to continue an action
Parabulia decreasing of the will caused by wishes, parallel acts
Impulsivity decreasing of voluntary capacity of inhibition, which determines
inadequate acts
Raptus violent behavioral reaction, without of any volitional control on a
limited conscience


CONSCIENCE
Process of reflecting the ego and the medium( psychological point of view)
Function of the cortical regions with optimal state of functioning (physiological
aspect)

a) Quantitative changes of conscience
Obtuse state is a state of moderately reduced alertness with slow responses and
diminished interest in the environment.
Hebetudinous state - the patient is dezinserted from reality
Torpor state disorientation, hypokinesia, reduced the affectivity and will (like
somnolence)
Dizziness- the patient has bradikinesia, bradipsihia, difficulties of spatial
orientation and orientation to self
Stupor is the next most severe level of impaired consciousness. Stuporous
patients must be vigorously stimulated to be aroused and engaged in conversation.
Stupor returns when stimulation ceases.
Sopor reduced reaction to psyhosensorial stimuli( liked marked somnolence)
Coma is state of unarousable unresponsiveness.

b) Qualitative changes of conscience
Delusional type changes of perception and temporal, spatial disorientation
Oneroide state vigil thinking with dreaming construction
Amentive state marked disturbance of the conscience of ego, total
disorientation, incoherence of thinking and speaking, disordered psychomotor
agitation
Crepuscular state marked alteration of sensorial reflection with motor
automatism( can determined coherent behavior, even on a psychotic context)


DEPERSONALIZATION AND DEREALISATION

Depersonalization - the feeling of one's own reality is temporarily lost
Derealisation - the patient may feel as if in a dream
a loss of ability to experience emotion and a disturbed perception of time
Neurosis, schizophrenia
epilepsy, migraine, encephalitis, and systemic metabolic disorders










(4) CLASSIFICATION OF PSYCHIATRIC DISORDERS

Competences: to know all types of classification of psychiatric disorders

Kraepelin's Clinico-Nosological Classification
1. From normal limits to psychiatric disorders
2. Major psychiatric disorders

1) From normal limits to psychiatric disorders
Neurosis
Neurasthenia
Obsessive -phobic neurosis
Hysteria
Mixed neurosis (motors)
Psychopathy (personality disorders)
Schizoid
Epileptic
Paranoid
Impulsive
Anankast
Histrionic
Mental retardation I

2) Major psychiatric disorders
Mental retardation II and III
Psychosis
Endogenous
Schizophrenia, mood disorder, paranoia, parafrenia
Exogenous
- External factors
Endo-exogenous
Postpartum, endocrine, epilepsy etc.
Dementia
Alzheimer, Pick, general progressive paralysis


Goals of psychiatric classifications
To establish a good diagnosis for an adequate treatment
To determine a common language for all psychiatrists
To explore other unknown causes of psychiatric disorders





WHO criteria of classification (ICD 10)

Organic, including symptomatic, mental disorders
F00 Dementia in Alzheimer's disease
F01Vascular dementia
F02Dementia in other diseases classified elsewhere
F03Unspecified dementia
F04Organic amnesic syndrome, not induced by alcohol and other substances
F05Delirium, not induced by alcohol and other psychoactive substances
F06Other mental disorders due to brain damage and dysfunction and to physical
disease
F06.0Organic hallucinosis
F07Personality and behavioural disorder due to brain disease, damage and
dysfunction
F08Other organic personality and behavioural disorder due to brain disease,
damage and dysfunction
F09Unspecified organic or symptomatic mental disorder

Mental and behavioural disorders due to psychoactive substance use
F10.-Mental and behavioural disorders due to use of alcohol
F11.-Mental and behavioural disorders due to use of opioids
F12.-Mental and behavioural disorders due to use of cannabinoids
F13.-Mental and behavioural disorders due to use of sedatives or hypnotics
F14.-Mental and behavioural disorders due to use of cocaine
F15.-Mental and behavioural disorders due to use of other stimulants, including
caffeine
F16.-Mental and behavioural disorders due to use of hallucinogens
F17.-Mental and behavioural disorders due to use of tobacco
F18.-Mental and behavioural disorders due to use of volatile solvents
F19.-Mental and behavioural disorders due to multiple drug use and use of other
psychoactive substances

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
F29 Unspecified nonorganic psychosis

Mood [affective] disorders
F30 Manic episode
F31 Bipolar affective disorder
F32 Depressive episode
F33 Recurrent depressive disorder
F34 Persistent mood [affective] disorders
F34.0 Cyclothymia
F34.1 Dysthymia
F34.8 Other persistent mood [affective] disorders
F34.9 Persistent mood [affective] disorder, unspecified
F38 Other mood [affective] disorders
F39 Unspecified mood [affective] disorder

Neurotic, stress-related and somatoform disorders
F40 Phobic anxiety disorders
F41 Other anxiety disorders
F42 Obsessive - compulsive disorder
F43 Reaction to severe stress, and adjustment disorders
F44 Dissociative [conversion] disorders
F45 Somatoform disorders
F48 Other neurotic disorders
F48.0 Neurasthenia
F48.1 Depersonalization - derealization syndrome
F48.8 Other specified neurotic disorders
F48.9 Neurotic disorder, unspecified

Behavioural syndromes associated with physiological disturbances and physical factors
F50 Eating disorders
F51 Nonorganic sleep disorders
F52 Sexual dysfunction, not caused by organic disorder or disease
F53Mental and behavioural disorders associated with the puerperium, not
elsewhere classified
F54Psychological and behavioural factors associated with disorders or diseases
classified elsewhere
F55 Abuse of non-dependence-producing substances
F59Unspecified behavioural syndromes associated with physiological
disturbances and physical factors

Disorders of adult personality and behaviour
F60 Specific personality disorders
F61 Mixed and other personality disorders
F62 Enduring personality changes, not attributable to brain damage and disease
F63 Habit and impulse disorders
F64 Gender identity disorders
F65 Disorders of sexual preference
F66 Psychological and behavioural disorders associated with sexual development
and orientation
F68 Other disorders of adult personality and behaviour
F69 Unspecified disorder of adult personality and behaviour

Mental retardation
F70 Mild mental retardation
F71 Moderate mental retardation
F72 Severe mental retardation
F73 Profound mental retardation
F78 Other mental retardation
F79 Unspecified mental retardation

Disorders of psychological development
F80 Specific developmental disorders of speech and language
F81 Specific developmental disorders of scholastic skills
F82 Specific developmental disorder of motor function
F83 Mixed specific developmental disorders
F84 Pervasive developmental disorders
F88 Other disorders of psychological development
F89 Unspecified disorder of psychological development

Behavioural and emotional disorders with onset usually occurring in childhood and
adolescence
F90 Hyperkinetic disorders
F91 Conduct disorders
F92 Mixed disorders of conduct and emotions
F93 Emotional disorders with onset specific to childhood
F94 Disorders of social functioning with onset specific to childhood and
adolescence
F95 Tic disorders
F98 Other behavioural and emotional disorders with onset usually occurring in
childhood and adolescence



DSM IV classification and criteria

Childhood and adolescence disorders
Delirium, dementia, cognitive disorders
Mental disorders caused by a medical condition
Psychiatric disorders induced by drugs
Schizophrenia and other psychotic disorders
Delusional disorders
Mood disorders
Anxiety disorders
Somatoform disorders
Factice disorders
Disociative disorders
Sexual identity disorders
Eating disorders
Sleeping disorder
Adjusting disorders
Personality disorders


DSM axes of diagnosis
I-clinical syndromes
II-personality disorder and mental retardation
III-somatic diseases
IV-psychosocial and medium issues
V-GAF






(5) ORGANIC MENTAL DISORDERS

Competences: To learn about history, epidemiology, etiology, nosological aspects,
diagnostic and treatment of all the organic mental disorders


ALZHEIMER'S DISEASE AND OTHER DEMENTIAS

Definition
Essential features of dementia:
Memory impairment
Impairment in at least one other cognitive domain (e.g., language and visual-
spatial skills)
Significant disturbance of work or social functioning

History
1906 - the German psychiatrist and neurologist Alois Alzheimer first described a
middle-aged patient who had suffered from a progressive dementia that affected
language, memory, and behavior. After the patient's death at age 55 years,
Alzheimer applied new staining techniques to the patient's brain tissue and
demonstrated the presence of what is now termed neurofibrillary tangles and
neuritic plaques in the neocortex and other brain regions

Epidemiology
Dementia of the Alzheimer's type 60% of old-age dementias
5 - 10% of people age 65
Cost society each year an estimated $100 billion
The greatest risk factors for developing dementia is age - the incidence and
prevalence of the disease double every 5 years after age 60

Etiology
Loss of cholinergic neurons
Increased frequency of Down syndrome (trisomy 21)
The gene coding for the amyloid precursor protein (APP) found in senile plaques
was localized to the same chromosome 21 region
Chromosome 19 - apolipoprotein E
Risk factors for Alzheimer's disease - prior head trauma and depression
Factors that may reduce the risk - higher educational level, larger brain size, and
postmenopausal estrogen therapy

Diagnosis And Clinical Features
The hallmark of dementia is memory impairment
Abstract thinking, judgment, personality, and language
Apraxia, agnosia, aphasia
Delusion, agitation, insomnia, anxiety, and depression

MI NI -MENTAL STATE EXAMI NATI ON

a) Orientation
(Score 1 point for correct response)
1. What is the year?
2. What is the season?
3. What is the date?
4. What is the day of the week?
5. What is the month?
6. Where are we? building or hospital?
7. Where are we? floor?
8. Where are we? town or city?
9. Where are we? county?
10. Where are we? state?

b) Registration
(Score 1 point for each object identified correctly, maximum is 3 points)
11. Name three objects at about one each second. Ask the patient to repeat them. If the
patient misses an object, repeat them until all three are learned.

c) Attention and calculation
(Score 1 point for each correct answer up to maximum of 5 points)
12. Subtract 7's from 100 until 65 (or, as an alternative, spell "world" backwards).

4) Recall
(Score 1 point for each correct answer, maximum of 3)
13. Ask for names of three objects learned in question 11.

5) Language and Executive Functions
14. Point to a pencil and a watch. Ask the patient to name each object. Score 1 point for
each correct answer, maximum of 2 points.
15. Have the patient repeat "No ifs, ands, or buts." Score one point if correct.
16. Have the patient follow a three-stage command: "(1) Take the paper in your right
hand. (2) Fold the paper in half. (3) Put the paper on the floor." Score 1 point for each
command done correctly, maximum of 3 points.
17. Write the following in large letters: "CLOSE YOUR EYES." Ask the patient to read
the command and perform the task. Score 1 point if correct.
18. Ask the patient to write a sentence of his or her own choice. Score 1 point if the
sentence has a subject, an object, and a verb.

19. Drawing the design. Ask the patient to copy the design. Score 1 point if all sides and
angles are preserved and if the intersecting sides form a quadrangle.


Results:
26 30 Normal
20 25 Mild Dementia
10 20 Moderate Dementia
0 10 Severe Dementia


Pathology And Laboratory Examination
Neuritic plaques (extracellular deposits of amyloidogenic proteins)
Neurofibrillary tangles (abnormal intracellular cytoskeletal filaments)
Computerized tomography [CT] or magnetic resonance imaging [MRI]
Blood count; serum urea nitrogen and glucose; serum electrolytes (Na, K, CO3,
Cl, Ca, P); B12; thyroid function tests; serological test for syphilis; and liver
function tests


















Differential Diagnosis
Vascular Dementia
Parkinson Disease Dementia
Huntington Disease Dementia
Fronto-temporal Dementia
Body Lewy Dementia
Post - Head Injury Dementia
HIV Dementia
Medical Conditions Dementia
(endocrine, metabolic, imune etc.)
Substance Dementia
(alcohol, drugs, medicines, toxines)
Multiple Etiology Dementia
Differential Diagnosis
Vascular Dementia - 10 to 20% of the dementias of old age - sudden onset of
illness and stepwise decline in cognitive function + focal neurological signs and
association with hypertension
Fronto-temporal Dementia - marked personality changes, relative preservation
of visuospatial skills, and executive dysfunction
Lewy body Dementia - visual hallucinations, delusions, fluctuating mental status,
and sensitivity to antipsychotic drugs
Alcohol and drugs may cause memory loss and other symptoms of dementia
Depressive Pseudodementia
Age-associated memory impairment

Course And Prognosis
Dementia of the Alzheimer's type is a progressive disease that eventually leads to
death, not directly from the dementing process but usually from intercurrent
illnesses
The rate of progression varies
Some patients become extremely demented within a year; others experience
plateaus for several years


TREATMENT
Cholinesterase Inhibitors
Tacrine
Donepezil
Metrifonate
Galantamine
Rivastigmine
Memantine-NMDA antagonist

Some Drugs Used to Treat Behaviors Associated With Dementia

Antipsychotics
Haloperidol
Thioridazine
Risperidone
Olanzapine
Quetiapine

Anxiolytics
Buspirone
Lorazepam
Clonazepam

Anticonvulsants
Carbamazepine
Divalproex sodium

Antidepressants
Fluoxetine
Sertraline
Paroxetine
Trazodone


Other Interventions
Attention to the Environment
Family Intervention
Nursing
Institution






DELIRIUM
a) impairment of consciousness and attention
(b) global disturbance of cognition
(c) psychomotor disturbances
(d) disturbance of the sleep-wake cycle
(e) emotional disturbances, e.g. depression, anxiety or fear, irritability, euphoria,
apathy or wondering perplexity
onset is usually rapid
the course diurnally fluctuating
the total duration of the condition less than 6 months.
evidence of cerebral dysfunction (e.g. an abnormal electroencephalogram, usually
but not invariably showing a slowing of the background activity) may be required
if the
diagnosis is in doubt


AMNESIC ORGANIC SYNDROME (KORSAKOV SYNDROME)

Diagnostic guidelines
presence of a memory impairment manifest in a defect of recent memory
(impaired learning of new material);
history or objective evidence of an insult to, or a disease of, the brain (especially
with bilateral involvement of the diencephalic and medial temporal structures);
absence of a defect in immediate recall of disturbances of attention and
consciousness, and of global intellectual impairment.
Confabulations, lack of insight and emotional changes (apathy, lack of initiative)
are additional, though not in every case necessary, pointers to the diagnosis.

Other mental disorders due to brain damage and dysfunction and to physical
disease
evidence of cerebral disease, damage or dysfunction or of systemic physical
disease, known to be associated with one of the listed syndromes;
a temporal relationship (weeks or a few months) between the development of the
underlying disease and the onset of the mental syndrome;
recovery from the mental disorder following removal or improvement of the
underlying presumed cause;
absence of evidence to suggest an alternative cause of the mental syndrome (such
as a strong family history or precipitating stress).
epilepsy;
limbic encephalitis;
Huntington's disease;
Head trauma; brain neoplasms; extracranial neoplasms with remote CNS effects
(especially carcinoma of the pancreas);
vascular cerebral disease, lesions or malformations;
lupus erythematosus and other collagen diseases; endocrine disease (especially
hypo and hyperthyroidism, Cushing's disease);
metabolic disorders (e.g., hypoglycaemia, porphyria, hypoxia);
tropical infectious and parasitic diseases (e.g. trypanosomiasis);
toxic effects of nonpsychotropic drugs (propranolol, levodopa, methyldopa,
steroids, antihypertensives, antimalarials).



ORGANIC MOOD SYNDROME
Disorders characterized by a change in mood or affect, usually accompanied by a
change in the overall level of activity.
presumed direct causation by a cerebral or other physical disorder whose presence
must either be demonstrated independently or assumed on the basis of adequate
history information.
not to represent an emotional response to the patient's knowledge of having, or
having the symptoms of a concurrent brain disorder.
Postinfective depression (e.g. following influenza) is a common example
MILD COGNITIVE DISORDER
This disorder may precede, accompany or follow a wide variety of infections and
physical disorders, both cerebral and systemic (including HIV infection).
Direct neurological evidence of cerebral involvement is not necessarily present,
but there may nevertheless be distress and interference with usual activities.
When associated with a physical disorder from which the patient recovers, mild
cognitive disorder does not last for more than a few additional weeks.

ORGANIC PERSONALITY SYNDROME
This disorder is characterized by a significant alteration of the habitual patterns of
premorbid behaviour.
The expression of emotions, needs, and impulses is particularly affected.
Cognitive functions may be defective mainly or even exclusively in the areas of
planning and anticipating the likely personal and social consequences, as in the
so-called frontal lobe syndrome.
syndrome occurs not only with frontal lobe lesions but also with lesions to other
circumscribed areas of the
brain.

(a) Consistently reduced ability to persevere with goal-directed activities, especially
those involving longer periods of time and postponed gratification;
(b) Altered emotional behaviour, characterized by emotional lability, shallow and
unwarranted cheerfulness (euphoria, inappropriate jocularity), and easy change to
irritability or short-lived outbursts of anger and aggression; in some instances apathy
may be a more prominent feature;
(c) Expression of needs and impulses without consideration of consequences or social
convention (the patient may engage in dissocial acts, such as stealing, inappropriate
sexual advances, or voracious eating, or may exhibit disregard for personal hygiene);
(d) Cognitive disturbances, in the form of suspiciousness or paranoid ideation, and/or
excessive preoccupation with a single, usually abstract, theme (e.g. religion,"right"
and "wrong");
(e) Marked alteration of the rate and flow of language production, with features such
ascircumstantiality, over-inclusiveness, viscosity, and hypergraphia;
(f) Altered sexual behaviour (hyposexuality or change of sexual preference).


POSTENCEPHALITIC SYNDROME
The syndrome includes residual behavioural change following recovery from
either viral or bacterial encephalitis.
Symptoms are nonspecific
It is often reversible
The manifestations may include general malaise, apathy or irritability, some
lowering of cognitive functioning (learning difficulties), altered sleep and eating
patterns, and changes in sexuality and in social judgement.
There may be a variety of residual neurological dysfunctions such as paralysis,
deafness, aphasia, constructional apraxia, and acalculia.

PSYCHIATRIC DISORDERS DUE TO HEAD INJURY
The syndrome occurs following head trauma (usually sufficiently severe to result
in loss of consciousness) and includes a number of disparate symptoms such as
headache, dizziness (usually lacking the features of true vertigo), fatigue,
irritability, difficulty in concentrating and performing mental tasks, impairment of
memory, insomnia, and reduced tolerance to stress, emotional excitement, or
alcohol.
Symptoms may be accompanied by feelings of depression or anxiety, resulting
from some loss of self-esteem and fear of permanent brain damage.
Some patients become hypochondriacal, embark on a search for diagnosis and
cure, and may adopt a permanent sick role.
The etiology of these symptoms is not always clear, and both organic and
psychological factors have been proposed to account for them.
(6) PSYCHOACTIVE SUBSTANCE USE DISORDERS

Competences: To know historical aspects, epidemiology, etiology, diagnosis and
treatment regarding psychoactive substance use disorders

Specific terms
Drug-dependence
Minor drugs
Major drugs
Tolerance
Psychic and physical dependence
Residual state


Psychiatric Disturbances Caused By Alcohol Consumption

Epidemiology
USA- 11% of American people used 28g alcohol every day
England-2% are diagnosed with dependence of alcohol
men/women = 4/1
Great transcultural differences
Great social costs

Etiopathogeny
Dopamine ways: mezolimbic, black substance, tegmentum - nucleus acumbens
(limbic system=euphoria, pleasant)
Culture, psychic, pleasant, behavior, neuronal ways-hyperfunction
Anxiolitic, antidepressive
Genetic hypothesis

Clinical forms
Acute intoxication with alcohol
Idiosyncratic alcohol intoxication
Dipsomania
Chronic intoxication with alcohol


1) Acute alcohol intoxication
A. Euphoric state euphoria, logorrhea, hipermnezia, absence of criticism etc. (0,3-1
gr).
B. Ebrios state verbal incoherence, bradikinesia, rapid changes of mood, motor changes
(1-1,5 gr).
C. Sleeping state alcoholemy of 1,5-4 gr
D. Coma > 4 gr.
E. 5 gr% death

2) I diosyncratic alcohol intoxication
Ingestion of a small quantity of alcohol
Changes of conscience- crepuscular type
Hallucinations or delusions
Psychomotor agitation
Antisocial acts-killing, suicide
Organic changes of the brain
24 h

3) Dipsomania
Periodical used of alcohol and the conscience is present after the period
The necessity to drink and neglected everything
Days-weeks
There are months between episodes
Relationship with ciclotimia, epilepsy, bipolar disorder

4) Chronic intoxication with alcohol
a. Abusive used withdrawal do not determine symptoms of organic or psychic
dependence;
b. Psychic dependence;
c. Organic dependence-the last state


Delirium tremens
Complication of chronic intoxication with alcohol
Without treatment-50%death
After 5 years of abuse
Organic dependence
After 2-4 days of abstinence
tremor
agitation
insomnia
inapetence
confusion
Auto and allo psychic disorientation
Visual hallucinations
Zoopsia
Generalized sweats
Hyperthermia - 40C
Generalized tremor
Pulse > 100/m
Without treatment-death




Politoxicomania
Hypnotics
Anxiolitcs (benzodiazepine, meprobamat)
Drugs
Withdrawal of alcohol is more dangerous compare with withdrawal of all other
drugs

TREATMENT
Disintoxication phase treatment of psychopathological, neurological and
somatic symptoms
Maintenance phase of the treatment
Psychotherapeutically phase
Reconstruction of familial, social and professional functions

Concept of drug dependence and abuse
aspects of history,
terminology evolution,
psychological, social and biological theories regarding drug dependence
etiopatogeny


OPIUM INDUCED MENTAL DISORDERS (OPIOID INTOXICATION)
Opium -Papaver Somniferum Album
42 alcaloise: morfina, tebaina, papaverina, codeina etc.
pils, teriak
drink, smoke
morfine injection
heroine injection
codein
Acute intoxication
Relax
Calm
Happiness
Calm satisfaction
High level for imagination and sensation
Hipoprosexia
Hipomnesia
Disartria
miosis
Nausea
Coma in overdose
Withdrawal
Disphoric mood
Muscular pain
Rinorea
Sweat
Midriasis
Nausea, vomiting
Diarrhea, fever
Insomnia, agitation


CANNABIS INDUCED MENTAL DISORDERS
Canabis indica
Hai- Levant, charas- Asia, chira -Africa
Tetrahidrocanabinol-active drug
Marihuana for smoking, hai-injection
After 10-30 minutes will appear the effect
Oral administration-intoxication with late onset and a longer evolution
Phases
Euphoric phase euthimia, good communication, somatic comfort
Exaltation of sensory and affective phase
Ecstatic phase
After few hours-sleep, then the second drinking
Risks
It is not a major withdrawal
Hostility, aggressive person
Extraordinary crime
Very dangerous persons
Cerebral atrophy


SEDATIVES AND HYPNOTICS INDUCED MENTAL DISORDERS
Benzodiazepine-acute intoxication
Motor changes
Disartria
Decrease of attention and memory
nistagmus
Stupor, coma
Chronic intoxication
Changes in mood
Decreasing of intellect
Antisocial and aggressive behavior
Decreasing of professional and social functioning
Symptoms of withdrawal
Sweat
puls > 100
tremor
insomnia
Nausea, vomiting
Tactile hallucinations
Visual or auditory hallucinations
Anxiety
Seizure

COCAINE INDUCED MENTAL DISORDERS
Erytroxylon Coca
Inhalation-plasmatic peak in 1 h
Acute intoxication happiness, 10-15 minutes, then total apathy and they try to
find the drug
Hallucinatory phase
After weeks, months of abuse
Multiple visual illusions
Patognomonic- haptice hallucinations
Suspicious, hostility, delusional thoughts
Lesions of nasal membrane
Deterioration of cognitive function


AMPHETAMINE OR SIMILARLY ACTING SYMPATHOMIMETIC INDUCED
MENTAL DISORDERS
Intoxication:
Euphoria
Logorrhea, hyperactivity, insomnia
Mouth, nose, lips-dried
Midriasis, anorexia, tachycardia
Arithmia
High blood pressure
Chronic intoxication
- Stereotype behavioral
- Paranoid psychosis like a paranoid schizophrenia
- Loss of weight, thoracic pain, seizures, fasciculation of muscle
Dependence
It is not a marked tolerance
Withdrawal with anergia and depression
Euphoria and hyperactivity with disphoria and absence of energy, in 10 days all
the symptoms disappeared
Decreasing of doses-decreasing symptoms of withdrawal


HALLUCINOGEN INDUCED MENTAL DISORDERS
Hallucinations
Loss the unity of the body
A lot of ideas without any content
Exacerbation of affectivity
Midriasis, tachycardia, sweat, pallor, lipotimia- after 30 minutes
Hyperacute phase-coma, seizures
Extreme anxiety, suicidal thoughts
(7) SCHIZOPHRENIA, SCHZOPHRENIFORM DISORDERS AND
SCHIZOAFFECTIVE DISORDER

Competences: To know issues regarding history, epidemiology, etiology, nosological
aspect, diagnostic and treatment of all these psychiatric disorders

Objectives
o Identify and define the two broad categories of symptoms in schizophrenia
o Identify the criteria for making the diagnosis of schizophrenia
o Know the basic epidemiology of the illness
o Identify the pathologic process that leads to brain tissue change
o Know the basic class of medications used for treatment and what symptoms they
target




Schizophrenia
What I t I s / What I t Isnt
Signs and Symptoms
Making the Diagnosis
Epidemiology - who gets it and when
Causes: Genetics/Environment/Biology
Course and Outcome
Treatment

SCHIZOPHRENIA is:
A brain disease
Complex
A Tragedy
Treatable
MISUNDERSTOOD!!!!

Schizophrenia is NOT:
A split personality
Caused by any guilts, acts, failures or weaknesses of the patient (or their
parents)
Caused by drugs
I got a bad disease
Up from my brain is where I bleed
Insanity it seems
Is got me by my soul to squeeze

Red Hot Chili Peppers

Signs & Symptoms of Schizophrenia

Division of symptoms into two broad groups
Positive: distortions or exaggerations of normal functions
Negative: lessening or diminution of normal functions

Positive Symptoms
Symptom
Hallucination
Delusions
Disorganized Speech
Bizarre Behavior

Function Distorted
Perception
Inferential Thinking
Thought / language
Behavioral Monitoring


Negative Symptoms
Alogia - lack of fluent speech
Affective blunting - lack of facial expression
Avolition - lack of motivation and drive
Anhedonia - lack of capacity to enjoy
Asociality - lack of interpersonal interaction

The importance of Negative symptoms
Impair ability to function in daily life
o Holding a job
o Attending school
o Forming friendships
o Having intimate family friendships
Dont respond as well to medicines

Cognitive Impairment
Not considered a negative symptom but is normal brain function that is impaired
or diminished
Cognition = mental faculties
o General intellect (IQ)
o Memory
o Attention
o Language skills
o Visuo-spatial skills
A core feature of the illness
Mild (not mental retardation) but significant






DSM-IV Criteria for Schizophrenia: The Basics
Characteristic symptoms for one month
Social/Occupational Dysfunction
Overall Duration > 6 months
Not attributable to mood disorder
Not attributable to substance use or general medical condition

- Characteristic symptoms
At least two of the following, each present for a significant portion of time during
a one month period:
o delusions
o hallucinations
o disorganized speech
o grossly disorganized or catatonic behavior
o negative symptoms

- Excluding a Mood Disorder
Many symptoms of depression overlap with negative symptoms
Difference in course
- mood disorders are episodic
- schizophrenia is chronic (though symptoms may fluctuate)

Excluding Drugs
Drugs do NOT cause schizophrenia
o amphetamines can cause psychosis
Patients with schizophrenia are more likely to use/abuse drugs
Drug use is often early on in the course of the illness


The Prevalence of Schizophrenia
Approximately 1% of the population affected (2.5-4.5 million in the U.S.)
Twice as common as Alzheimers, five times more common than multiple
sclerosis sixty times more common than muscular dystrophy
tremendous financial cost to our society
o approximately $104 billion dollars annually
Age of Onset
Average age of onset is between 20 and 39
Mean age at 1st psychotic episode:
- 21 years for men
- 26 years for women

Genetics of Schizophrenia
Adoption studies. Family studies and Twin studies all indicate there is a strong
genetic component to the etiology of this illness




Pathoetiology
Schizophrenia is a Neurodevelopmental Disorder
- The origins of this illness are most likely due to abnormality in the early stages of
brain growth
- Manifested in subtle deficits during childhood

Symptoms of Schizophrenia in Childhood
- developmental delays in speech and motor skills
- motor abnormalities
- cognitive deficits - poor academic performance
- behavioral abnormalities
- abnormalities in social interaction/affect

Brain development over time
- If this is a neurodevelopmental syndrome, why not onset until after adolescence?
- Answer: brain development is a very long process occurring throughout childhood
and through the second decade of life
- The patholophysiology of this disease is in late maturational events

Abnormal Pruning
- In schizophrenia, there may be abnormally robust pruning
o leads to greater loss of cortical gray matter than normal
o important connections may be cut - leads to misconnections, lack of
connections


Decreased Tissue / I ncreased CSF

Abnormal Brain Structure
Tissue volume is decreased in the cerebrum
o Mostly gray matter
o Most prominent in frontal and temporal lobe
Rationale for auditory hallucinations
o Cells are not decreased, but their branches or connections are decreased
Overall, a SUBTLE structural change

Functional Abnormality
What is NOT subtle is the functional abnormality
The brain works by constant communication of brains regions that work together
as a circuit
Schizophrenia is a disease in which there is an abnormality in the connections
between cells
- A disease at the synaptic level

Course for Schizophrenia:

Chronic
Prodromal phase
o precedes the active phase, usually by about 1 year
o Mild changes in behavior
Active phase
o psychotic symptoms
Residual phase
o similar to prodromal phase, though role impairment may be worse
o psychotic symptoms may persist

Outcome:
This is a devastating illness
Most patients never marry or reproduce
Most are unable to work
15% suicide

Treatment of Schizophrenia
This is a treatable illness!
Medical management is primary
o Education of patient & family is also key
Antipsychotic medications
Dopamine Hypothesis
o excess dopamine causes psychotic symptoms
o probably over-simplistic more than one neurochemical system involved

Antipsychotic Medication (or Antipositive Medication)
Older class
- Thorazine, Haldol, Prolixin
- Blocked dopamine only
- Side effects: parkinsonism
Newer class
- Olanzapine, Risperdal, Clozapine
- Blocks other neurotransmitters as well
- However, there is no effective antipsychotic that doesnt block dopamine

In general, psychotic symptoms respond very well to treatment
Negative symptoms and cognitive dysfunction DO NOT respond nearly as well to
medication

SCHIZOAFFECTIVE DISORDER
A diagnosis of schizoaffective disorder should be made only when both definite
schizophrenic and definite affective symptoms are prominent simultaneously, or
within a few days of each other, within the same episode of illness, and when, as a
consequence of this, the episode of illness does not meet criteria for either
schizophrenia or a depressive or manic episode.

Schizoaffective Disorder Manic Type
A disorder in which schizophrenic and manic symptoms are both prominent in the
same episode of illness.
The abnormality of mood usually takes the form of elation, accompanied by
increased self-esteem and grandiose ideas, but sometimes excitement or
irritability are more obvious and accompanied by aggressive behaviour and
persecutory ideas.
increased energy, overactivity, impaired concentration, and a loss of normal social
inhibition.
Delusions of reference, grandeur or persecution may be present, but other more
typically schizophrenic symptoms are required to establish the diagnosis.
florid psychoses with an acute onset
although behaviour is often grossly disturbed, full recovery generally occurs
within a few weeks

Schizoaffective Disorder Depressive Type
A disorder in which schizophrenic and depressive symptoms are both prominent
in the same episode of illness.
Depression of mood is usually accompanied by several characteristic
o depressive symptoms or behavioural abnormalities such as retardation,
insomnia, loss 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;
Schizoaffective episodes of the depressive type are usually less florid and
alarming than schizoaffective episodes of the manic type
tend to last longer and the prognosis is less favourable
majority of patients recover completely
eventually develop a schizophrenic defect.