Psychotic Disorders & Depression

1. Psychotic Disorders & Depression Related Etiology, Epidemiology, and Symptomology

2. Schizophrenia • Disturbance that lasts for at least 6 months and includes at least 1 month of active-phase symptoms. Other Related Disorders • Shizophreniform Disorder • Delusional Disorder • Brief Psychotic Disorder • Shared Psychotic Disorder • Psychotic Disorder due to a General Medical Condition • Substance-Induced Psychotic Disorder * From the Diagnostic and Statistical Manual, 4th edition (DSM-IV)

3. Diagnostic Criteria (Symptoms) • Two or more must be present for a significant portion of 1 month • Delusions • Hallucinations • Disorganized Speech (e.g., frequent derailment or incoherence) • Grossly disorganized or catatonic behavior • Negative symptoms, i.e., affective flattening, alogia, or avolition

4. Social/Occupational Dysfunction • For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement.

5. Duration • Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A (symptoms) in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

6. Subtypes • Paranoid type - primary aspect is the presence of recurring delusions or auditory hallucinations. Cognitive/affective functioning remain relatively intact. • Disorganized type - disorganized speech and behavior, and flat or inappropriate affect (silliness, inappropriate laughter). • Catatonic type - psychomotor immobility or excessiveness, extreme negativism, mutism, echolalia. • Undifferentiated type - criteria met for Criterion A but are not met for the Paranoid, Disorganized, or Catatonic types. • Residual type - absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. Continuing evidence of the disorder such as flat affect, odd beliefs, unusual perceptual experiences.

7. Associated Features • Thought fragmentation • Euphoric Mood • Dysphoric Mood • Somatic/sexual dysfunction • Psychomotor retardation/excitation • Guilt obsession • Suicidal ideology • Changes in appetite and sleep patterns • Difficulty concentrating due to preoccupation with internal stimuli • Lack of insight • Odd mannerisms - (smiling, facial expressions, body postures) • Inability to experience pleasure

8. Causes • Very complex • Stress does not cause schizophrenia but can exacerbate symptoms • Combination of neural (genetic) and environmental factors • No evidence of neuronal death or deterioration such as in Alzheimer’s • Neurotransmission abnormalities • Prenatal features of molecular biological abnormalities • Is not a “split” personality

9. Prevalence and Incidence • Prevalence estimates range from .5 % to 1 %. • Incidence rates are estimated to be approximately 1 per 10,000 people per year. • Onset generally occurs between late adolescence and late 20’s/early 30’s.

10. Depression Criteria for Major Depressive Episode • Five or more of the following symptoms have been present during the same 2-week period and represent a change from pervious functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. • Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

11. Criteria for MDE cont’d • Insomnia or hypersomnia nearly every day • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

12. Single Episode Presence of a single MDE The MDE is not better accounted for by Schizoaffective disorder and is not superimposed on other psychotic disorders There has never been a manic episode, a Mixed Episode, or a Hypomanic Episode. Recurrent Presence of two or more MDE’s To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a MDE. Bullets 2 and 3 from Single Episode apply here as well. Major Depressive Disorder

13. Associated Features • Tearfulness • Irritability • Brooding • Obsessive rumination • Anxiety • Phobias • Excessive worry over physical health • Complaints of pain (headaches, joint, abdominal, etc.) • Feelings of hopelessness and helplessness • Suicidality - 15% die by suicide (increases four-fold over age 55)

14. Prevalence • 10% - 25% for women • 5% - 12% for men • Appear to be unrelated to ethnicity, education, income, or marital status. • Onset can occur at any time but generally occurs in mid-20’s.

15. Causes • Signs of biochemistry abnormalities (neurotransmission interruptions) • Can have a genetic predisposition of the illness but may not develop unless environmental factors are present.

16. Dysthymia Diagnostic Criteria for Dysthymic disorder • Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. • Presence, while depressed, of two or more of the following: • Poor appetite or overeating • Insomnia or hypersomnia • Low energy or fatigue • Low self-esteem • Poor concentration or difficulty making decisions • Feelings of hopelessness • No MDE • Irritability • Loss of ability to experience pleasure