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Home , Emil Kraepelin, Ganser syndrome

26/02/2020

Outline

• • history Diagnosis and Classification • international variation Michael Shaw • modern classification Consultant • MRCPsych course year 1 • acute psychotic disorders Psychotic disorders module • Other chronic psychotic disorders

Schizophrenia: Kraepelin • Emil Kraepelin (1856 - 1926) • Founder of modern scientific • Unitary concept of : • praecox (1887) • , hebephrenia, • brain with progressive deterioration • vs • manic-depressive insanity by prognosis (now seen as mood disorders) • 13% recovered • Symptoms can be in either category • but diagnosis about specific pattern of symptoms

Schizophrenia: Bleuler

• Eugen Bleuler (1911 - 1939) • Gave name : Schizophrenia (1908) • psychological disorder: splitting of mind (emotional vs intellectual) • Believed condition was not a dementia – seen recovery • Deteriorating attacks, rather than recurrence – no cure • First to identify positive & negative symptoms • fundamental symptoms • loosening of associations, affective blunting, , ambivalence (‘four As’) • accessory symptoms • , , catatonia • simple schizophrenia

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Schizophrenia: Schneider

• (1887 - 1967) • attention on early acute phase of illness • ‘symptoms of first rank’ (1938) • pathognomonic of schizophrenia in absence of organic brain disease • ‘loss of ego boundaries’ • form basis of ICD-10, DSM-IV core criteria • ‘symptoms of second rank’ • perplexity, blunting, hallucinations, delusions

First rank symptoms US traditions

• auditory hallucinations • influenced by Freud & Bleuler • thought echo • diagnosis based on ‘four As’ • 3rd person voices • autism, inappropriate affect, ambivalance, loose • commentary voices associations • thought insertion or withdrawal • Meyer • thought broadcasting • psychobiology: illness as adaptation to changing environment • US/UK diagnostic project • passivity feelings / delusions of control • narrowing definition of schizophrenia • somatic hallucinations • Neo-Kraepelinians • delusional perception • critical of psychodynamic view • diagnostic criteria

US / UK diagnostic project : UK / German traditions 1971 • Kraepelinian • Cooper JE et al. (1972) Psychiatric Diagnosis in New York and London. Maudsley • narrow concept of schizophrenia Monograph 20. Oxford: OUP. • strongly influenced by Schneider’s first rank • Far higher rates of schizophrenia in US than UK (ICD 9) symptoms • Far lower rates of in US than UK (0.5% vs. 6.9% of hospital discharge diagnoses) • Looser diagnostic criteria for schizophrenia used in US (DSM- • SOVIET UNION II) • Rosenhans 1972 study “Being Sane in Insane Places” • Use for political purposes, to discredit political concluded diagnosis of schizophrenia in US often is subjective dissidents @ trial – Been condemned and unreliable.

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Japan: Renaming Schizophrenia 2004 Seishin Bunretsu Byo (“mind-split-disease”) Scandinavian traditions

• Schizophrenia was inaccurate • narrow concept of schizophrenia • Negative image & legacy of inhumane • schizophreniform psychosis treatment • Langfeldt • psychosis with better prognosis • ‘Integration Disorder’ Togo Shitcho Sho • psychogenic psychoses • Away from Kraepelinian disease concept to • Wimmer (1916), Stromgren Vulnerability model (to reflect outcomes) • predisposed individuals • Reduce stigma • multi-dimensional classification • Improve communication of diagnosis • Sjobring (1919)

Anti – Psychiatry French traditions Movement • Morel (1857) • Challenged the medical concept • theory of degeneration • Magnan (1895) • Emphasised social context • psychoses in normals / degenerates • Prominent thinkers include R.D Laing/ • transitory delusional states David Cooper • bouffee delirante (acute nonaffective/ non schizophrenia • Schizophrenia: an understandable reaction to psychotic state (ICD 10 = Acute polymorphic psychotic conflicts between family & self, or through trauma. disorder)) • Believe represents a problem, many humans have. • non-schizophrenic chronic delusional states: • Schizophrenia is a disease vs impact of • no FTD/ IQ impairment environmental factors (the social cradle) • chronic interpretative psychosis ≈ • chronic hallucinatory psychosis ≈ paraphrenia • Intelligent/ sensitive beings confronted by a ‘Mad • chronic imaginative psychosis World’

Classifying psychotic states Classifying psychotic states

• List the disorders in which psychotic symptoms • List the disorders in which psychotic symptoms can occur can occur • Non-affective psychotic disorders • schizophrenia • schizophreniform disorder • schizoaffective disorder • delusional disorder • Affective psychoses • • major depressive disorder • Substance induced psychotic disorder • Psychotic disorder due to general medical condition

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Modern classification I Modern classification II

• ICD-10 • DSM-IV • at least one of • positive symptoms for > one month, either • thought echo, thought insertion, thought withdrawal, • at least two of delusions, hallucinations, disorganised thought broadcasting, delusions of control, commentary speech, catatonic behaviour, negative symptoms voices, bizarre delusions • OR one of bizarre delusions, commentary or discussing • OR at least two of voices • hallucinations, thought disorder, catatonic behaviour, • markedly impaired functioning negative symptoms • continuous signs of disturbance for > 6m (positive or negative • present for > one month symptoms) • Certain exclusions

Modern classification III DSM V • Criterion A: At least one of – delusions; hallucinations; • DSM V disorganised speech; plus another from these or one from negative symptoms; disorganised or catatonic • From 2013 behaviour • Elimination of special attribution to bizarre • Criterion B: Social/occupational/self care dysfunction delusions • Criterion C: Continuous signs for 6 months with 1 • Elimination of special attribution to Schneiderian month meeting Criterion A (less if treated) first-rank auditory hallucinations • Criterion D: Schizoaffective & Major Mood Exclusion • Requirement for at least one of 3 positive symptoms – hallucinations, delusions, disorganised • Criterion E :Substance/ general medical condition Ex speech. • Criterion F: ASD/communication disorder (childhood • Removal of subtypes onset) need prominent delusions or hallucinations along with other criteria

ICD-11 6A2- Schizophrenia or other Differences between ICD-10 & primary psychotic disorders DSM-V schizophrenia • In release form for endorsement May 2019 and • ICD-10 has greater emphasis on first rank implementation January 2022 symptoms • Retains schizophrenia as a term • ICD-10 divides schizophrenia into subtypes • “significant impairments in reality testing” manifest as… • DSM-V requires longer duration of some • Deviate from cultural or subcultural norms symptoms • Do not arise from another disorder • DSM-V requires impairment of functioning • First, multiple and continuous episodes - no subtypes • Duration of symptoms of one month • Acute and transient psychosis – no , max severity 2 weeks, duration a few days to 3 months max

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OPCRIT Schizophrenia: reliability • Operational criteria checklist for psychotic and affective disorders • Jakobsen et al (2005) • Generates diagnoses according to 12 diagnostic • Evaluated patients with diagnosis of schizophrenia using systems (DSM, ICD etc) OPCRIT criteria • High PPV (0.87) for ICD-10 diagnosis • Initial 3 factor solution produced +ve/ -ve & • Near perfect agreement (kappa = 0.98) for DSM-IV diagnosis disorganisation factors. • Diagnosis of schizophrenia is highly reliable • Application suggested 5 factors to ensure good validity in diagnosis: Paranoia/ 1st rank delusions/ 1st rank hallucinations/ Disorganisation/ Negative sx. • Reliable, rapid & valid approach to polydiagnostic assessment

Schizophrenia: Schizophrenia – polydiagnostic studies • Jager et al (2003) Psychopathology • Jansson & Parnas (2006) • Clinical features of patients with diagnosis of psychotic • Review of 92 polydiagnostic studies disorders compared (n = 1476) • Insufficient validity to support any one definition over another • ICD-10 schizophrenia characterised by more negative • 1st rank symptoms not associated with family history or poor symptoms and lower global functioning prognosis • older than patients with ATPD (acute & transient psychotic disorder) • Long duration criteria and exclusion of affective states restricts • younger than patients with DD & SAD diagnosis to chronic stable patients • descriptive validity of schizophrenia supported • Patients meeting all definitions are a more severely ill group rather than a strongly valid subgroup • Conceptual and construct validity for schizophrenia remains under-researched

Dimensions of major Schizophrenia - validity psychoses • Serretti & Olgiati (2004) • Allardyce et al (2007) Schizophrenia Bulletin • factor analysis of 1294 patients • clinical utility does not provide construct validity of • best fit with 5 factors schizophrenia • No clear distinction between normality & psychosis • positive symptoms • 18 month incidence of symptoms 4.4% of general • negative symptoms population in UK NPMS • disorganisation • alternative approaches to classification • mania • refine categories: new subtypes • • identify dimensions: 5 factor model • search for proximal indicators

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Diagnosis: Psychosis: a disorder of aberrant salience • Disease construct: measureable phenotype • Kapur (2003) Am J Psychiatry • Observations about psychosis • Construct is valid combining aetiological, sx, • Psychosis evolves slowly prognostic & treatment specificity • Dopamine releasers do not cause psychosis after single exposure • Delusions are symptoms of inferential logic • Construct is useful • Hallucinations are abberantly recognised internal perceptions • Dopamine normally mediates (but does not create) • Diagnostic construct is acceptable to those expression of motivational saliences in response to carrying its label individual experiences • In psychosis, there is assignment of inappropriate • Authors argue, that these do not apply to salience and motivational significance to external events and internal representations Schizophrenia and other psychotic disorders. • “dampen the salience” of abnormal experiences via blocking of D2 receptors.

Salience dysregulation Salience dysregulation syndrome • Van Os (2009) Br J Psychiatry • Psychotic experiences are 10x more common than psychotic disorders: psychotic disorders blur into normality • Specific symptoms of diagnostic validity are lacking except • Manic symptoms in mania • Developmental impairment in schizophrenia • Utility enhanced by using both categorical & dimensional aspects • categories: affective expression, developmental expresssion • dimensions: positive, disorganisation, negative, depressive, manic, developmental cognitive • Salience dysregulation syndrome

Schizoaffective disorder: origin

• Kasanin (1933) • florid psychosis in young adult at a time of emotional turmoil • convenient category for patients with both affective and schizophrenic symptoms, simultaneously or sequentially

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Schizoaffective disorder: Schizoaffective disorder: ICD- definitions 10 • schizophrenia with incidental affective • ICD-10 symptoms • criteria and schizophrenia criteria must be present within the same episode of the disorder and • affective disorder with incidental schizophrenic concurrently for at least part of the time. symptoms • both mood symptoms and schizophrenic symptoms must be prominent • co-morbid schizophrenia and mood disorder • unrelated psychotic disorder • genuine interface of schizophrenia and bipolar disorder • a mixture of all the above

Schizoaffective disorder: Schizoaffective disorder: DSM-V reliability • Vollmer-Larsen et al (2006) Acta DSM - V • Evaluated patients with diagnosis of SAD using OPCRIT • Major mood episode must be present for criteria majority of illness duration. • n = 59 • None met DSM-IV criteria • Longitudinal instead of cross sectional dx • 6 possibly met ICD-10 criteria • Improve reliability, diagnostic stability & • recommended not to use diagnosis validity

Schizoaffective disorder: long Acute psychotic disorder term • Jager et al (2004) Acta • psychogenic psychosis • 15 year follow-up of patients with psychotic and affective disorders (n = 241) • cycloid psychosis • Patients with diagnosis of schizoaffective disorder had • bouffées délirantes prognosis similar to that of affective disorders • hysterical psychosis

• modern classification

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Psychogenic psychosis Cycloid psychosis (German)

• Stromgren (1974) • Leonhard (1957) • reaction to psychic trauma • endogenous psychosis, sudden onset • mixed symptoms, phasic course • popular diagnosis in Scandinavia • unrelated to BAD / schizophrenia • 30% later re-diagnosed as BAD or • Perris (1974) schizophrenia • perplexity, delusions of reference, hypo/hyperkinesia, ecstasy, pananxiety • good early prognosis • high rate of relapse

Bouffees delirantes (French) Hysterical psychosis

• Brief reactive psychosis • psychosis with secondary gain • Magnan • Ganser syndrome (1898) • short-lived psychosis + • psychotic symptoms in prison with retrospective • constitutional weakness • vorbeireden - approximate answers to questions • probably mainly schizophreniform • hysterical, factitious or ? • Hollander & Hirsch (1964) • narrower concept than ATPD • acute, dramatic psychosis after severe stress usually in women with histrionic personality disorders

DSM V: Brief Psychotic Episode Modern classification • ICD-10 • One or more psychotic symptoms • acute and transient psychotic disorders • Hallucinations/delusions/ bizarre behaviour/ • with or without schizophrenic symptoms disorganised speech • with or without associated acute stress • Affective sx/ disorientation/ catatonia/ impaired attention. • Acute onset • 2 weeks or less • Sudden onset • Perplexity & puzzlement common • Longer than 1 day • Complete recovery within a few months (1-3 months) • Full remission within 1/12 • Full return of functioning

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ATPD: psychopathology ATPD: diagnostic stability

• Marneros et al (2005) European Psych • Singh et al (2004) Br J Psychiatry • Compared psychopathology in ATPD to schizophrenia and • 3 year follow-up of first episode of psychois, n = schizoaffective disorder 168 • Higher frequency of “rapidly changing delusional topics”, “rapidly changing mood”, anxiety in ATPD • ATPD (n = 32) compared to schizophrenia and affective psychosis • ATPD diagnosis stable in 73% women and 14% men • men: 43% change to schizophrenia, 24% to affective psychosis • women: 18% change to schizophenia, 9% to affective psychosis

Terms for psychotic disorder Delusional disorder • Paranoia – persecutory, conspiracy theory • Paraphrenia – late onset, lack of negative sym • ICD-10 • Erotomania - Clerambault • 3 months of or set of delusions that are not completely impossible (cf “bizarre” in • delusional jealousy - Othello Schizophrenia and cf DSM V) • monosymptomatic hypochondriacal psychosis • no persistent hallucinations • dysmorphophobia • Encompasses all except first two on • Capgras’ syndrome - imposter previous slide • Cotard’s syndrome – delusion of non-existance • Folie à deux – shared delusions

Delusional Disorder DSM - V Thank You – • No longer must be ‘Non Bizarre’ • New exclusion criteria: sx must not be better explained Questions? by conditions such as OCD or with absent insight/ delusional beliefs. • No longer separates delusional disorder with shared delusional disorder.

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