psicose/ Psychosis ( doenças mentais ).ppt

Psicose , doenca mental , que aflige diversas pessoas

1. “Psychosis”
Wolfgang Krahl MD MA
Isar Amper Klinikum – Klinikum München Ost
Germany
Faculty of Medicine
Catholic University of Mozambique
2017
[email protected]

i.nez

2. "Psychosis“ and “Neurosis”
In the past the concepts of Neurosis and Psychosis were
included in most systems of classification. Neither of these
terms is used as an organising principle in ICD 10 or in
DSM IV. Instead of following the neurotic-psychotic
dichotomy, the disorders are now arranged in groups
according to major common themes.

3. Neurosis - a widely used collective term for psychiatric
disorders that have three things in
common…not accompanied by organic brain disease…not
psychoses…discrete onset rather than a continuous
development from early life.

4. Psychosis refers to an abnormal condition of the mind
described as involving a "loss of contact with reality".
Psychosis is a descriptive term for the hallucinations,
delusions and impaired insight that may occur. Depending
on its severity, this may be accompanied by unusual or
bizarre behavior, as well as difficulty with social interaction
and impairment in carrying out daily life activities.
Psychosis is a descriptive term and does not explain a
cause.

5. Disorders in which psychosis is a defining feature
Schizophrenia
Substance induced psychotic disorders
Schizophreniform Disorder
Schizoaffective Disorder
Delusional Disorder
Brief Psychotic Disorder
Shared Psychotic Disorder
Psychotic Disorder due to general medical condition

6. Disorders in which psychosis can be an associated
feature
Mania
Depression
Cognitive Disorders
Alzheimer Dementia
Borderline Personality Disorder
Substance dependent disorders - Addiction

7. Schizophrenia

8. F20-F29 Schizophrenia, Schizotypal and
Delusional Disorders
F20 Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post-schizophrenic depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified

9. F21 Schizotypal disorder

F22 Persistent delusional disorders
F22.0 Delusional disorder
F22.8 Other persistent delusional disorders
F22.9 Persistent delusional disorder, unspecified

F23 Acute and transient psychotic disorders
F23.1 Acute polymorphic psychotic disorder with symptoms of
schizophrenia
F23.2 Acute schizophrenia-like psychotic disorder
F23.3 Other acute predominantly delusional psychotic disorders
F23.8 Other acute and transient psychotic disorders
F23.9 Acute and transient psychotic disorder, unspecified
F20-F29 Schizophrenia, Schizotypal and
Delusional Disorders

10. Schizophrenia
Schizophrenia is a severe mental disorder. Its estimated
risk in life is 0.5-1.0 %. The disease is more common in
males and usually begins before the age of 30. Many
persons with schizophrenia do not recognize that they are
suffering from a disease and refuse treatment.
Schizophrenia is in most cases a long-term illness which
requires long term treatment and rehabilitation. There are
potent drugs and psychosocial interventions available.

11. Schizophrenia: Age and Gender
30
20
10
0
P
a
t
i
e
n
t
s

(
%
)
12-1415-1920-2425-2930-3435-3940-4445-4950-5455-59
Female
Male
Age group (y)

Hafner et al 1993

12. Schizophrenia: Age and Gender
Schizophrenia has a later onset in females than in males
and this difference has been found to be about 5 years in
most studies. Considering all measures of onset into
account, like earliest sign of mental disorder, first psychotic
symptoms and hospitalisation, it is suggested that women,
as a group, have a significantly later age of onset. The
peak age of onset in males is from 21-25 years whereas in
females the peak age of onset is from 25-32 years

13. Schizophrenia
Schizophrenia typically begins in late adolescence or early
adulthood. It is characterized by profound disruptions in
thinking, affecting language, perception, and a sense of
self. It often includes psychotic experiences such as
hearing voices or delusions. It can impair functioning
through the loss of an acquired capability to earn one's own
livelihood or the disruption of studies.

14. Stages of Schizophrenia
The patient has full functioning (100%) early in life and is
virtually asymptomatic (stage I).
During a prodromal phase (stage II) starting in the teens,
there may be odd behaviors and subtle negative symptoms
The acute phase of the illness usually announces itself
fairly dramatically in the twenties (stage III) with positive
symptoms, remissions, and relapses.
The final phase of the illness (stage IV) may begin in the
forties or later, with prominent negative and cognitive
symptoms and some waxing & waning during its course,
but more of a burnout stage of continuing disability.

15. Course of schizophrenia
Continuous
Episodic with progressive deficit
Episodic with stable deficit
Episodic remittent
Incomplete remission
Complete remission

16. Why does someone develop schizophrenia?
The etiology and pathogenesis of schizophrenia is not well
known
It is accepted, that schizophrenia is „the group of
schizophrenias“ which origin is multifactorial:
internal factors – genetic, inborn, biochemical
external factors – stress, trauma, infection of CNS,

17. Schizophrenia is not caused by:
Inadequate parenting
Overzealous mothers
Poor family relations
It is not split personality

18. Schizophrenia - Heritability
Heritability is above 50%
‘Recurrence’ risk
Both parents 89%
Monozygotic twin 50%
Father or mother only 10%
Full sibling 8%
Half sibling 2.5%
First cousin 2.3%

19. Structural changes in brain
Hippocampus, amygdala, parahippocampus
Disordered hippocampal pyramidal cells
Correlation between cell disorder and severity
May be due to maternal influenza in 2
nd
trimester

21. Dopamine hypothesis
Amphetamine (very high doses)  paranoia, delusions,
auditory hallucination
Also exacerbates symptoms of schiz.
Effects blocked by DA antagonist chlorpromazine
Phenothiazines (incl. chlorprom.) & all other typical
neuroleptics block D2 receptors and alleviate (+)
symptoms.

22. Cannabis use and Schizophrenia
Review of 35 longitudinal population-based studies of
psychosis,
1

odds ratio
ever use of cannabis 1.4
frequent use 2.1
Possible interaction with gene (COMT)
Moore T et al (2007), Lancet, 370, 319- 328

23. Schizophrenia: the affected person may
Talk to himself
Gesture to himself
Dress in layers in any weather
Fail to bathe and get a haircut
Gain an odd interest in ordinary things
May even believe he is God
See things
Feel people are out to get them
Believe in all sorts of conspiracies

24. Schizophrenia: the affected person may
Have strange ideas that no amount of evidence to the
contrary can dislodge
Be unable to work
Stop talking or greatly reduce conversation
Appear lazy, unmotivated and uninterested
May look like he has dementia
Lose the ability to get and keep friends
Be tense

25. The Criteria of Diagnosis (ICD-10)
For the diagnosis of schizophrenia is necessary
•presence of one very clear symptom - from point a) to d)
•or the presence of the symptoms from at least two groups - from
point e) to h)
for one month or more:
a)the hearing of own thoughts, the feelings of thought withdrawal,
thought insertion, or thought broadcasting
b)the delusions of control, outside manipulation and influence, or the
feelings of passivity, which are connected with the movements of the
body or extremities, specific thoughts, acting or feelings, delusional
perception
c)hallucinated voices, which are commenting permanently the behavior
of the patient or they talk about him between themselves, or the other
types of hallucinatory voices, coming from different parts of body
d)permanent delusions of different kind, which are inappropriate and
unacceptable in given culture

26. The Criteria of Diagnosis (ICD-10)
e)the lasting hallucination of every form
f)blocks or intrusion of thoughts into the flow of thinking and resulting
incoherence and irrelevance of speach, or neologisms
g)catatonic behavior
h)„the negative symptoms”, for instance the expressed apathy, poor
speech, blunting and inappropriatness of emotional reactions
i)expressed and conspicuous qualitative changes in patient’s
behavior, the loss of interests, hobbies, aimlesness, inactivity, the
loss of relations to others and social withdrawal
•Diagnosis of acute schizoform disorder (F23.2) – if the conditions
for diagnosis of schizophrenia are fulfilled, but lasting less than one
month
•Diagnosis of schizoaffective disorder (F25) - if the schizophrenic
and affective symptoms are developing together at the same time

27. Positive and Negative Symptoms
Negative Positive
Alogia Hallucinations
Affective flattening Delusions
Avolition-apathy Bizarre behaviour
Anhedonia-
Asociality
Positive formal thought
disorder
Attentional impairment
Andreasen N.C., Roy M.-A., Flaum M.: Positive and negative symptoms. In:
Schizophrenia, Hirsch S.R. and Weinberger D.R., eds., Blackwell Science, pp. 28-45, 1995

28. Positive symptoms
Delusions: false beliefs kept despite contrary evidence.
(believing you are the Prophet Muhammed)
Hallucinations: false perceptions (usually hearing voices)
mental disturbance: illogical thought, incoherent speech,
word usage shifts.

29. Negative Symptoms
No emotional expression
Little speech
Withdrawal from social world
Reduced personal hygiene

30. F20.0 Paranoid Schizophrenia
Paranoid schizophrenia is characterized mainly by
delusions of persecution, feelings of passive or active
control, feelings of intrusion, and often by megalomanic
tendencies also. The delusions are not usually systemized
too much, without tight logical connections and are often
combined with hallucinations of different senses, mostly
with hearing voices.
Disturbances of affect, volition and speech, and catatonic
symptoms, are either absent or relatively inconspicuous.

31. F20.1 Hebephrenic Schizophrenia
Hebephrenic schizophrenia is characterized by
disorganized thinking with blunted and inappropriate
emotions. It begins mostly in adolescent age, the behavior
is often bizarre. There could appear mannerisms,
grimacing, inappropriate laugh and joking,
pseudophilosophical brooding and sudden impulsive
reactions without external stimulation. There is a tendency
to social isolation.
Usually the prognosis is poor because of the rapid
development of "negative" symptoms, particularly flattening
of affect and loss of volition. Hebephrenia should normally
be diagnosed only in adolescents or young adults.
Denoted also as disorganized schizophrenia

32. F20.2 Catatonic Schizophrenia
Catatonic schizophrenia is characterized mainly by motoric
activity, which might be strongly increased (hypekinesis) or
decreased (stupor), or automatic obedience and
negativism.
We recognize two forms:
productive form — which shows catatonic excitement,
extreme and often aggressive activity. Treatment by
neuroleptics or by electroconvulsive therapy.
stuporose form — characterized by general inhibition of
patient’s behavior or at least by retardation and slowness,
followed often by mutism, negativism, fexibilitas cerea or by
stupor. The consciousness is not absent.

33. F20.5 Residual schizophrenia

Absence of prominent delusions, hallucinations,
incoherence or grossly disorganized behavior. Continuing
evidence of the disturbance through two or more residual
symptoms [e.g. emotional blunting, social withdrawal].

34. F23 Acute and Transient Psychotic Disorders
The criteria include the following features:
acute beginning (within two weeks)
presence of typical symptoms (quickly changing
“polymorphic symptoms”)
presence of typical schizophrenic symptoms.
Complete recovery usually occurs within a few months,
often within a few weeks or even days.
The disorder may or may not be associated with acute
stress, defined as usually stressful events preceding the
onset by one to two weeks.

35. Differential Diagnosis
Psychotic Disorder Due to a General Medical Condition
Substance-Induced Psychotic Disorder
Mood Disorder with Psychotic Features
Brief Psychotic Disorder
Delusional Disorder
Psychotic Disorder NOS
Borderline Personality Disorder
PTSD

36. Features of Schizophrenia
Positive symptoms
Delusions
Hallucinations
Cognitive deficits
Attention
Memory
Verbal fluency
Executive
function
(eg, abstraction)
Functional Impairments
Work/school
Interpersonal relationships
Self-care
Negative symptoms
Anhedonia
Affective flattening
Avolition
Social withdrawal
Alogia
Mood symptoms
Depression/Anxiety
Aggression/Hostility
Suicidality
Disorganization
Speech
Behavior

37. Treatment
Primary prevention of schizophrenia is not possible
Treatment of schizophrenia has three main components:
1. Medication to relieve symptoms and prevent relapse
2. Education and
3. Psychosocial interventions to help patients/families
Rehabilitation to help patients reintegrate into the
community. With medication and care, almost half of
sufferers can expect a full recovery. However, in the
remaining cases, it can follow a chronic or recurrent course
with residual symptoms and serious limitations in daily
activities.

38. Medication
The acute psychotic schizophrenic patients will respond
usually to antipsychotic medication.
classical antipsychotics
eg: chlorpromazine, fluphenazine, haloperidol, perazin,
perphenazine
atypical antipsychotics
clozapine, (risperidone)
((amisulpiride, olanzapine, quetiapine, sertindole))

39. Antipsychotics WHO ELM (2017)
Chlorpromazin
Haloperidol
Fluphenazine
Fluphenazine Decanoat Depot-Inj. 25mg
Risperidone
Clozapin
Treatment of extrapyramidal symptoms
Biperiden Tbl., 2mg (Hydrochlorid)

40. Community and social support
Patients with schizophrenia may need help from people in
their family or community.
Ensuring that a person with schizophrenia continues to get
treatment after hospitalization is important.
Encouraging the patient to continue treatment and assisting
him or her in the treatment process can positively influence
recovery.
A positive approach may be helpful and perhaps more
effective in the long run than criticism.

41. Family education
It is important for family members to learn all they can
about schizophrenia when they have to take care of a
family member who has been discharged from the hospital.
Family psychoeducation includes teaching various coping
strategies and problem-solving skills. It is a cognitive-
behavioral treatment approach to family therapy.
This approach helps families to deal more effectively with
their ill relative and to contribute to an improved outcome
for the patient.

42. Schizophrenia Treatment: Psychological
Those who have family benefit most from families who:
are informed about the illness have support and skills to
deal with the ill family member
Family member skills:
low key
low demand
use simple sentences
privacy for both the patient and themselves
able to ignore the inconsequential features of the illness
able to respond to dangerous behavior
accept that their ill member may never be like he once was

43. Caregivers burden worldwide
There is no doubt that the extended family system helped
enormously in alleviating the suffering of psychiatric
patients.
On the other side the burden of the caregivers was not
taken into account. Research all over the world done
mainly during the last decade shows unanimously that
there is a heavy burden on many of the caregivers
wherever they live.

44. Traditional treatment
N %
Chinese 26 79
Indian 8 80
Malay 7 100
Amount spent for treatment
Traditional Medical
Chinese 2 – 12 000 Rm 0 – 200 Rm
Indian 100 – 5000 Rm 0 – 30 Rm
Malay 170-10 000 Rm 0 – 50 Rm

45. Financial situation
of patients suffering from schizophrenia,
data from 50 patients in Malaysia
Patients average income before illness:457 RM
Patients average income after illness:222 RM
Loss of income: 51,5%

46. WHO 5-Year-Outcome Study of Schizophrenia
Industrialised Countries
Country outcome best worst
 
Aarhus, Denmark 6 40
London, UK 5 14
Moskau, Russia 6 21
Prag, Tschechenia 9 23
Washington, DC, USA 17 23
Developing Countries
 
Agra, India 42 10
Cali, Colombia 11 21
Ibadan, Nigeria 33 10
Jablensky, A.; Sartorius,N.; Ernberg, G.; et al. (1992) Schizophrenia: manifestations, incidence and course in different cultures. A
World Health Organization ten-country study. Psychological Medicine (suppl. 20).

47. Prognosis
More than half of schizophrenic patients have a favorable
course, so that no or little problems exist within the social
integration. A solid partnership, a good social network,
female gender, an acute onset and consistent drug therapy
favor the chances of recovery. Without treatment with
antipsychotic medications about 85% of patients with
schizophrenia suffer relapse, with antipsychotic medication
only 15%.

48. Muito Obrigado