PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders 1.1 1.

1a
Schizophrenia-Spectrum and Other Psychotic Disorders
June 18, 2015
Dr. Jose Gerardo Los Baños
Thought Withdrawal
OUTLINE o belief that one’s thoughts have been removed by an
I. Introduction outside force.
A. Psychotic Disorder Thought insertion
B. Key Features that define Psychotic Disorders o alien’s thoughts have been put into one’s mind.
II. Schizophrenia Delusions of control
III. Schizophreniform Disorder o belief that one’s body or actions are being acted on or
IV. Brief Psychotic Disorder manipulated by some outside force.
V. Schizoaffective Disorder 2. HALLUCINATIONS
VI. Substance/Medication Induced Psychotic Disorder  Perception- like experiences that occur without an external
VII. Psychotic Disorder Due to another medical condition stimulus.
VIII. Catatonia  Vivid and clear, with the full force and impact of normal
A. Catatonic Disorder due to another medical condition perceptions and not under voluntary control.
B. Unspecified Catatonia  May occur in any sensory modality. May involve one or
IX. Other Specified Schizophrenia Spectrum & Other more senses: Auditory, visual, somatic olfactory,
Psychotic Disorder gustatory, tactile.
X. Unspecified Schizophrenia Spectrum and other Auditory hallucinations
Psychiatric Disorder o Most common in Schizophrenia and related disorders.
XI. Delusional Disorder o Usually experienced as voices, whether familiar or
XII. Culture-Bound Syndromes unfamiliar, that are perceived as distinct from the
XIII. Treatment of Psychotic Disorders individual’s own thoughts.
* Source DSM V and Kaplan o May occur while falling asleep (hypnagogic) or
** Addt’l from DSM V not in the lecture waking up (hypnopompic)
3. DISORGANIZED THINKING (SPEECH)
INTRODUCTION  a formal thought disorder typically inferred from the
Abnormality (Nice to know) individual’s speech may switch from one topic to another
 Dysfunctional is when behavior interfere with the person’s (derailment or loose associations)
ability to function in daily life  Answers to questions may be obliquely related or
 Distress when the behavior causes discomfort and to the completely unrelated (tangentiality)
individual or to others around him or her.  Rarely, speech may be so severely disorganized that it is
 Deviant (unusual) behaviors, such as chronic lying and nearly incomprehensible and resembles receptive aphasia
stealing, or hearing voices when no one is around, lead to in its linguistic disorganization (incoherence or "word
judgments of abnormality. salad")
 Dangerous behaviors and feelings are of potential harm to 4. GROSSLY DISORGANIZED OR ABNORMAL MOTOR
the individual, such as suicidal gestures, or to others, such BEHAVIOR (INCLUDING CATATONIA)
as excessive aggression.  manifest in a variety of ways ranging from child-like
 Together they make up mental health professionals’ "silliness" to unpredictable agitation
definition of behaviors or feelings as abnormal or  Problems may be noted in any form of goal-directed
maladaptive. behavior, leading to difficulties in performing activities of
A. PSYCHOTIC DISORDERS daily living.
Psychosis CATATONIC BEHAVIOR
Definition  Marked decrease in reactivity to the environment
 Gross impairment in reality testing leading to incorrect  Negativism- resistance to instructions
 Mutism- complete lack of verbal and motor response
evaluation of the accuracy of perception and thoughts
 Stupor- maintaining a rigid, inappropriate or bizarre
thus making incorrect inferences about external reality
posture
even in the face of contrary evidence.
 Catatonic excitement- purposeless and excessive motor
Description activity without obvious cause
 Behaviorally appreciable as severe impairment of social  Although catatonia has historically been associated with
and personal functioning characterized by social schizophrenia, catatonic symptoms are non-specific and
withdrawal and inability to perform the usual may occur in other mental disorders and medical
household and occupational roles. conditions
 Generally viewed as a mental disorder that markedly 5. NEGATIVE SYMPTOMS
interferes with a person’s capacity to meet life’s  Two negative symptoms particularly prominent in
everyday demands. schizophrenia:
 In a specific sense, refers to a thought disorder in which  Diminished emotional expression
reality testing is grossly impaired.  reductions in the expression of emotions in the face, eye
 Traditionally emphasized as loss of reality testing and contact, intonation of speech (prosody) and movements of
the hand, head and face that normally give an emotional
impairment in mental functioning which manifests as
response to speech. Avolition
delusions, hallucinations, confusion, and impaired
 decrease in motivated self – initiated purposeful activities
memory
 Other negative symptoms:
Alogia
KEY FEATURES OF PSYCHOTIC DISORDERS o diminished speech output
1. DELUSION Anhedonia
 Are fixed beliefs that are not amenable to change in light o decreased ability to experience pleasure from positive
of conflicting evidence. May include a variety of themes. stimuli or a degradation in the recollection of pleasure
 Deemed bizarre if they are clearly implausible and not previously experienced.
understandable to same- culture peers and do not derive Asociality
from ordinary life experiences. o Refers to the apparent lack of interest in social
 Some examples are: interactions
Nihilistic delusions
o involve the conviction that a major catastrophe will
occur.

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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
SCHIZOPHRENIA
DIAGNOSTIC CRITERIA
A. Two (or more) of the following, each present for a
significant portion of time during a 1 -month period (or less
if successfully treated). At least one of these must be (1),
(2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or
incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (i.e., diminished emotional
expression or avolition)
B. For a significant portion of the time since the onset of the
disturbance, level of functioning in one or more major
areas, such as work, interpersonal relations, or self-care, is
markedly below the level achieved prior to the onset (or
when the onset is in childhood or adolescence, there is
failure to achieve expected level of interpersonal,
academic, or occupational functioning).
C. 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 (i.e., active-phase 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 by two or
more symptoms listed in Criterion A present in an
attenuated form (e.g., odd beliefs, unusual perceptual
experiences).
D. Schizoaffective disorder and depressive or bipolar disorder
with psychotic features have been ruled out because either
1. no major depressive or manic episodes have occurred
concurrently with the active-phase symptoms, or
2. if mood episodes have occurred during active-phase
symptoms, they have been present for a minority of the
total duration of the active and residual periods of the
illness.
E. The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a
communication disorder of childhood onset, the additional
diagnosis of schizophrenia is made only if prominent
delusions or hallucinations, in addition to the other
required symptoms of schizophrenia, are also present for
at least 1 month (or less if successfully treated).
Specify if:
 The following course specifiers are only to be used after a 1-
year duration of the disorder and if they are not in
contradiction to the diagnostic course criteria.
o First episode, currently in acute episode:
 First manifestation of the disorder meeting the
defining diagnostic symptom and time criteria.
 Acute episode - time period in which the symptom
criteria are fulfilled.
o First episode, currently in partial remission:
 Partial remission - period of time during which an
improvement after a previous episode is maintained
and in which the defining criteria of the disorder are
only partially fulfilled.
o First episode, currently in full remission:
 Full remission - period of time after a previous
episode during which no disorder-specific symptoms
are present.
o Multiple episodes, currently in acute episode:
 Multiple episodes may be determined after a
minimum of two episodes (i.e., after a first episode, a
remission and a minimum of one relapse).
o Multiple episodes, currently in partial remission
o Multiple episodes, currently in full remission
o Continuous:
 Symptoms fulfilling the diagnostic symptom criteria of
the disorder are remaining for the majority of the
illness course, with subthreshold symptom periods
being very brief relative to the overall course.
o Unspecified
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Specify if:
o With catatonia
Specify current severity:
 Severity is rated by a quantitative assessment of the primary
symptoms of psychosis, including
o Delusions
o Hallucinations
o Disorganized speech
o Abnormal psychomotor behavior, and
o Negative symptoms.
 Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point scale
ranging from 0 (not present) to 4 (present and severe).
Note: Diagnosis of schizophrenia can be made without using
this severity specifier.
DIAGNOSTIC FEATURES
 Heterogeneous clinical syndrome
 Characteristic symptoms involve a range of cognitive,
behavioral, and emotional dysfunctions
 NO single symptom is pathognomonic.
 The diagnosis involves recognition of constellation of
signs and symptoms associated with impaired
occupational or social functioning.
 At least two Criterion A symptoms must be present for
a significant portion of time during a 1-month period or
longer.
 At least one of these symptoms must be the clear
presence of delusions (Criterion A1), hallucinations
(Criterion A2), or disorganized speech (Criterion A3).
Grossly disorganized or catatonic behavior (Criterion
A4) and negative symptoms (Criterion A5) may also be
present.
 Schizophrenia involves impairment in one or more major
areas of functioning (Criterion B).
 If the disturbance begins in childhood or adolescence, the
expected level of function is not attained.
 Some signs of the disturbance must persist for a
continuous period of at least 6 months (Criterion C).
 Prodromal symptoms often precede the active phase,
and residual symptoms may follow it, characterized by
mild or subthreshold forms of hallucinations or delusions.
 Negative symptoms are common in the prodromal
and residual phases and can be severe.
 Individuals who had been socially active may become
withdrawn from previous routines.
 Such behaviors are often the first sign of a disorder.
 Mood symptoms and full mood episodes are common in
schizophrenia and may be concurrent with active-phase
symptomatology.
 However, a schizophrenia diagnosis requires the presence
of delusions or hallucinations in the absence of mood
episodes.
 Mood episodes, taken in total, should be present for only a
minority of the total duration of the active and residual
periods of the illness.
ASSOCIATED FEATURES SUPPORTING DIAGNOSIS
Patients with schizophrenia may present with:
 Inappropriate affect
e.g., laughing in the absence of an appropriate stimulus
 Dysphoric mood
In the form of depression, anxiety, or anger
 Disturbed sleep pattern
e.g., daytime sleeping and nighttime activity
 Lack of interest in eating or food refusal
 Depersonalization, derealization, and somatic
concerns may occur and sometimes reach delusional
proportions.
 Anxiety and phobias
 Cognitive deficits are common and are strongly linked to
vocational and functional impairments.
 These can include decrements in declarative memory,
working memory, language function, and other
executive functions, as well as slower processing
speed.
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
 Abnormalities in sensory processing and inhibitory
capacity, as well as reductions in attention, are also
found.
 Show social cognition deficits, including:
 SLE, wherein, for reasons not
of mind)
 genetics, some tissues are not
stimuli as meaningful, perhaps leading to the
generation of explanatory delusions.
 These impairments frequently persist during
symptomatic remission.
 Anosognosia may be present in some individuals
 Unawareness of illness is typically a symptom of
schizophrenia itself rather than a coping strategy.
 Most common predictor of non-adherence to
treatment, and it predicts higher relapse rates,
increased number of involuntary treatments, poorer
psychosocial functioning, aggression, and a poorer
course of illness.
 Hostility and aggression can be associated with
schizophrenia, although spontaneous or random assault is
uncommon.
Aggression is more frequent for:
 Younger males
 Individuals with a past history of violence, non-
adherence with treatment, substance abuse, and
impulsivity.
 Differences are evident in multiple brain regions
between groups of healthy individuals and persons with
schizophrenia.
 Differences are evident in cellular architecture, white
matter connectivity, and gray matter volume in a
variety of regions such as the prefrontal and temporal
cortices.
 Reduced overall brain volume has been observed, as
well as increased brain volume reduction with age.
 Brain volume reductions with age are more pronounced
in individuals with schizophrenia than in healthy
individuals.
 Individuals with schizophrenia appear to differ from
individuals without the disorder in eyetracking and
electrophysiological indices.
 urological soft signs common in individuals with
schizophrenia include
 impairments in motor coordination, sensory integration,
and motor sequencing of complex movements
 Left-right confusion
 Disinhibition of associated movements
 Minor physical anomalies of the face and limbs may
occur.
FOUR A’S OF SCHIZOPHRENIA
 Bleuler identified specific fundamental (or primary)
symptoms of schizophrenia:
o Associational disturbances of thought, especially
looseness
o Affective disturbances
o Autism
o Ambivalence
MODELS OF VIRAL AND IMMUNE CAUSES OF
SCHIZOPHRENIA
Retroviral Infection
 Virogene hypothesis
o Altered expression of the host's own
genes and the genes of the host's
offspring toward the development of
schizophrenia
Current or active viral
infection  Past viral infection hypothesis
o Virus infecting certain brain tissues
early in life create vulnerability to
schizophrenia
Virus-activated
immune-pathology  In theory, viral reactivation might
result in an induction of
schizophrenic psychopathology.
ARBOLEDA, Leigh | PAMPLONA, Hosanne | SENA, Gab | WONG, Anjeh
1.1
Auto-immune
pathology  Schizophrenia has been
hypothesized to be an idiopathic
autoimmune disease, such as RA or
entirely clear but probably involving
recognized as self and become the
target of immune response.
Maternal infection
 2nd trimester exposure to influenza
epidemics are more likely to give
birth to offspring at ↑ risk for
schizophrenia.
 Prenatal rubella infection may ↑ risk
for development of schizophrenia
and other non-affective psychotic
disorders
SUBTYPES OF SCHIZOPHRENIA
Disorganized Type. The disorganized type of schizophrenia is
characterized by a marked regression to primitive, disinhibited,
and unorganized behavior and by the absence of symptoms
that meet the criteria for the catatonic type.
Paranoid Type. The paranoid type of schizophrenia is
characterized by preoccupation with one or more delusions or
frequent auditory hallucinations. Characteristically with
delusions of grandeur or persecution.
Catatonic Type. The classic feature of the catatonic type is a
marked disturbance in motor function; this disturbance may
involve stupor, negativism, rigidity, excitement, or posturing.
Sometimes the patient shows a rapid alteration between
extremes of excitement and stupor.
Undifferentiated Type. Frequently, patients who clearly have
schizophrenia cannot be easily fit into one type or another.
Residual Type. The residual type of schizophrenia is
characterized by continuing evidence of the schizophrenic
disturbance in the absence of a complete set of active
symptoms or of sufficient symptoms to meet the diagnosis of
another type of schizophrenia.
OTHER SUBTYPES (Addt’l from KAPLAN)
Paraphrenia
Oneiroid
Deficit Schizophrenia
Criteria for Deficit Schizophrenia
1. At least two (2) of the features must be present and of
clinically significant severity
 Restricted affect
 Diminished emotional range
 Poverty of speech
 Curbing of interest
 Diminished sense of purpose
 Diminished social drive
2. Two or more of this feature should be present for the
preceding 12 mos. and were always present during
periods of clinical instability.
3. Two or more of these endring features are also idiopathic,
that is not secondary to factors other than disease
process.
 Anxiety
 Drug effect
 Suspiciousness
 Hallucinations or delusions
 Mental retardation
 Depression
4. The patient meets DSM criteria for schizophrenia
** THIS SECTION IS NOT COMPREHENSIVE ANY
FURTHER INQUIRIES SHOULD BE DIRECTED TO KAPLAN
EPIDEMIOLOGY INFECRION AND BIRTH SEASON
 Studies have pointed to gestational and birth complications,
exposure to influenza epidemics, or maternal starvation
during pregnancy, Rhesus factor incompatibility, and an
excess of winter births in the etiology of schizophrenia.
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
SOCIOECONOMIC AND CULTURAL FACTORS
 Downward drift hypothesis
Suggests that affected persons move into, or fail to rise
out of, a low socioeconomic group because of this illness
 Social causation hypothesis
Proposes that stresses experienced by members of low
socioeconomic groups contribute to the development of
schizophrenia.
ETIOLOGY GENETIC FACTORS
 Closeness of the relationship to an affected relative.
(e.g., first- or second-degree relative) is correlated with
likelihood of a person having schizophrenia
 Most commonly implicated: long arms of chromosome 5,
11, & 18, the short arm of chromosome 19 & the X
chromosome. Also implicated: loci on chromosomes 6, 8,
& 22.
STRESS-DIATHESIS MODEL
 A person may have specific vulnerability (diathesis) that
when acted on by a stressful influence, allows the
symptoms of schizophrenia to develop.
NEUROPATHOLOGY
 Primarily in limbic system and the basal ganglia
Including neuropathological or neurochemical
abnormalities in the cerebral cortex, the thalamus, and
the brainstem.
 Loss of brain volume appears to result from reduced
density of the axons, dendrites, and synapses that
mediate associative functions of the brain.
Cerebral Ventricles
 Lateral and third ventricular enlargement and some
reduction in cortical volume. Observed during the earliest
stages of the disease.
Reduced Symmetry
 In several brain areas in schizophrenia, namely temporal,
frontal, and occipital lobes. Believed by some investigators
to originate during fetal life which is indicative of a
disruption in brain lateralization during neurodevelopment
Limbic System
 ↓ in the size of the region including the amygdala, the
hippocampus, and the parahippocampal gyrus.
Hippocampus is also functionally abnormal as indicated
by glutamate transmission disturbances.
Prefrontal Cortex
 Anatomical abnormalities in the prefrontal cortex in
schizophrenia and functional deficits in the prefrontal brain
imaging region have also been demonstrated.
Thalamus
 norepinephrine reward neural system could
Basal Ganglia and Cerebellum
 Many patients with schizophrenia show odd movements,
even in the absence of medication-induced movement
disorders (e.g., tardive dyskinesia).
 Movement disorders involving the basal ganglia (e.g.,
Huntington's disease, Parkinson's disease) are the ones
most commonly associated with psychosis.
Neural Circuits
 Observation of the relationship among impaired working
memory performance, disrupted prefrontal neuronal
integrity, altered prefrontal, cingulate, and inferior parietal
cortex, and altered hippocampal blood flow provides
strong support for disruption of the normal working
memory neural circuit in patients with schizophrenia
Brain Metabolism
 Patients with schizophrenia had lower levels of
phosphomonoester and inorganic phosphate and higher
levels of phosphodiester.
Applied Electrophysiology
 Many schizophrenia patients have abnormal records,
increased sensitivity to activation procedures, decreased
alpha activity, increased theta and delta activity, possibly
more epileptiform activity than usual, and possibly more
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1.1
left-sided abnormalities than usual. They also exhibit an
inability to filter out irrelevant sounds and are extremely
sensitive to background noise.
Complex Partial Epilepsy
 Schizophrenia-like psychoses have been reported to occur
more frequently in patients with complex partial seizures,
especially seizures involving the temporal lobes.
Evoked Potentials
 In patients with schizophrenia, the P300 has been
reported to be statistically smaller than that in comparison
groups. Other evoked potentials reported to be abnormal
in patients with schizophrenia are the N100 and the
contingent negative variation.
Eye Movement Dysfunction
 The inability to follow a moving visual target accurately is
the defining basis for the disorders of smooth visual
pursuit and disinhibition of saccadic eye movements seen
in patients with schizophrenia.
Psychoneuroimmunology
 Immunological abnormalities that have been associated
with patients who have schizophrenia:
 Decreased T-cell interleukin-2 production
 Reduced number and responsiveness of peripheral
lymphocytes
 Abnormal cellular and humoral reactivity to neurons
 Presence of brain-directed (antibrain) antibodies.
Psychoneuroendocrinology
 One carefully done report, however, has correlated
persistent nonsuppression on the dexamethasone-
suppression test in schizophrenia with a poor long-term
outcome.
BIOLOGICAL FACOTRS NEUROTRANSMITTERS
DOPAMINE HYPOTHESIS
Posits that schizophrenia results from too
much dopaminergic activity.
Dopamine
Excessive dopamine release in patients
with schizophrenia has been linked to the
severity of positive psychotic symptoms.
Serotonin excess as a cause of both
Serotonin
positive and negative symptoms
Anhedonia
Impaired capacity for emotional gratification
and the decreased ability to experience
Norepinephrine pleasure.
selective neuronal degeneration within the
account for this aspect of schizophrenic
symptoms
Some patients with schizophrenia have a
loss of GABAergic neurons in the
hippocampus.
GABA
Loss of inhibitory GABAergic neurons could
theoretically lead to the hyperactivity of
dopaminergic neurons
Glutamate has been implicated because
ingestion of phencyclidine, a glutamate
antagonist, produces an acute syndrome
similar to schizophrenia.
Glutamate
Hypotheses proposed about glutamate
include those of hyperactivity, hypoactivity
& glutamate-induced neurotoxicity
schizophrenia have demonstrated
Acetyl-choline &
decreased muscarinic and nicotinic
Nicotine
receptors in selected areas of brain
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders 1.1

PSYCHOSOCIAL AND PSYCHOANALYTIC THEORIES  Schisms and Skewed Families

PSYCHOANALYTIC THEORIES
 Psychoanalytic theory postulates that the various
symptoms of schizophrenia have symbolic meaning for
individual patients.
 For example, fantasies of the world coming to an end may
indicate a perception that a person's internal world has
broken down.
 Feelings of inferiority are replaced by delusions of
grandeur and omnipotence.
 Hallucinations may be substitutes for a patient's inability to
deal with objective reality and may represent inner wishes
or fears.
 Delusions, like hallucinations, are regressive, restitutive
attempts to create a new reality or to express hidden fears
or impulses.
PROPONENT VIEWS
Schizophrenia resulted from developmental
fixations that occurred earlier than those
culminating in the development of neuroses.
SIGMUND FREUD
These fixations produce defects in ego
development and Freud postulated that such
defects contributed to the symptoms of
schizophrenia.
Due to distortions in the reciprocal
relationship between the infant and the
mother, the child is unable to separate from,
and progress beyond, the closeness and
MARGARET
complete dependence that characterize the
MAHLER
mother-child relationship in the oral phase of
development.
As a result, the person’s identity never
becomes secure.
Defect in ego functions permits intense
hostility and aggression to distort the
PAUL FEDERN
mother-infant relationship, which leads to
eventual personality disorganization and
vulnerability to stress.
Schizophrenia as a disturbance in
interpersonal relatedness.
Px's massive anxiety creates a sense of
HARRY STACK unrelatedness that is transformed into
SULLIVAN parataxic distortions, which are usually,
but not always, persecutory.
Schizophrenia is an adaptive method used
to avoid panic, terror, and disintegration of
the sense of self.
LEARNING THEORIES
 Children who later have schizophrenia learn irrational
reactions and ways of thinking by imitating parents who
have their own significant emotional problems
 Poor interpersonal relationships of persons with
schizophrenia develop because of poor models for
learning during childhood
FAMILY DYNAMICS
 In a study of British 4-year-old children, those who had a
poor mother-child relationship had a six-fold increase in
the risk of developing schizophrenia.
 Double Bind
o Concept formulated by Gregory Bateson and Donald
Jackson to describe a hypothetical family in which
children receive conflicting parental messages about
their behavior, attitudes, and feelings.
o Bateson’s Hypothesis:
 Children withdraw into a psychotic state to
escape the unsolvable confusion of the double
bind.
o Abnormal patterns of family described by Theodore
Lidz
o Schism between the parents, one parent is overly
close to a child of the opposite gender.
o Skewed relationship between a child and one parent
involves a power struggle between the parents and
the resulting dominance of one parent.
o These dynamics stress the tenuous adaptive capacity
of the person.
 Pseudomutual and Pseudohostile
o Described by Lyman Wynne
o Some families suppress emotional expression by
consistently using pseudomutual or pseudohostile
verbal communication.
o In such families, a unique verbal communication
develops, and when a child leaves home and must
relate to other persons, problems may arise.
o The child's verbal communication may be
incomprehensible to outsiders.
 EXPRESSED EMOTION
o Parents or other caregivers may behave with overt
criticism, hostility, and too much involvement toward a
person with schizophrenia is high.
PREVALENCE
 Lifetime prevalence: approx. 0.3%-0.7%
 There is reported variation by race/ethnicity, across
countries, and by geographic origin for immigrants and
children of immigrants.
 The sex ratio differs across samples and populations
 An emphasis on negative symptoms and longer duration
of disorder (associated with poorer outcome) shows higher
incidence rates for males
 Definitions allowing for the inclusion of more mood
symptoms and brief presentations (associated with better
outcome) show equivalent risks for both sexes
PREVALENCE OF SCHIZOPHRENIA IN SPECIAL
POPULATION
Population Prevalence Rate (%)
General Population 1
Non-twin sibling of a
schizophrenia patient 8
Child with one parent with
schizophrenia 12
Dizygotic twin of
schizophrenia patient 12
Child of two parents with
schizophrenia 40
Monozygotic twin of
schizophrenia patient 47
DEVELOPMENT AND COURSE
Onset of psychotic features:
 Between the late teens and the mid-30s
Onset prior to adolescence is rare
 Peak age at onset for the first psychotic episode:
Males: Early- to mid-20s
Females: Late-20s
Usually begins before age 25
Peak ages of onset:
Men – 10 to 25 years
Women – 25 to 35 years with second peak occurring in middle
age(with 3 to 10% of women present with disease onset after
age 40)
 Onset may be abrupt or insidious
 Majority manifest a slow & gradual development of variety
of clinically significant S/Sx
 Half of these complain of depressive symptoms.
 Earlier age at onset has traditionally been seen as a
predictor of worse prognosis.
 However, the effect of age at onset is likely related to
gender, with males having worse premorbid adjustment,
lower educational achievement, more prominent negative
symptoms and cognitive impairment, and in general a
worse outcome.

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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
 Impaired cognition is common, and alterations in cognition
are present during development and precede the
emergence of psychosis, taking the form of stable
cognitive impairments during adulthood.
 Cognitive impairments may persist when other symptoms
are in remission and contribute to the disability of the
disease.
 Predictors of course and outcome are largely unexplained,
and course and outcome may not be reliably predicted.
 The course appears to be favorable in about 20% of those
with schizophrenia, and a small number of individuals are
reported to recover completely.
 However, most individuals with schizophrenia still require
formal or informal daily living supports,
 Many remain chronically ill, with exacerbations and
remissions of active symptoms
 Others have a course of progressive deterioration
 Psychotic symptoms tend to diminish over the life course,
perhaps in association with normal age-related declines
in dopamine activity.
 Negative symptoms
 More closely related to prognosis than positive
symptoms
 Tend to be the most persistent
 Furthermore, cognitive deficits associated with the illness
may not improve over the course of the illness.
 Essential features of schizophrenia are the same in
childhood, but it is more difficult to make the diagnosis:
 Delusions & hallucinations may be less elaborate
 Visual hallucinations are more common and should be
distinguished from normal fantasy play
 Disorganized speech occurs in many disorders with
childhood onset
 Autism spectrum disorder
 Attention-deficit/hyperactivity disorder
 Childhood-onset cases tend to resemble poor-outcome
adult cases, with gradual onset and prominent negative
symptoms.

 Children who later receive the diagnosis of schizophrenia
are more likely to have experienced:
 Nonspecific emotional-behavioral disturbances and
psychopathology
 Intellectual and language alterations
 Subtle motor delays
 Late-onset cases - onset after age 40 years
 Overrepresented by females, who may have married.
 Course is often characterized by a predominance of
psychotic symptoms with preservation of affect and
social functioning.
 Such late-onset cases can still meet the diagnostic criteria
for schizophrenia, but it is not yet clear whether this is the
same condition as schizophrenia diagnosed prior to mid-
life (prior to age 55 years).
RISK AND PROGNOSTIC FACTORS ENVIRONMENTAL
 Incidence of schizophrenia and related disorders is higher
for children growing up in an urban environment and for
some minority ethnic groups.
FEATURES WEIGHING TOWARD GOOD TO POOR
PROGNOSIS IN SCHIZOPHRENIA
GOOD PROGNOSIS POOR PROGNOSIS
factors
sexual and work
sexual, and work histories
histories
behaviour
(especially
Depressive disorders)
e symptoms
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1.1
disorders
GENETIC AND PHYSIOLOGICAL
 There is a strong contribution for genetic factors in
determining risk for schizophrenia; although most
individuals diagnosed with schizophrenia have no family
history of psychosis.
 Liability is conferred by a spectrum of risk alleles,
common and rare, with each allele contributing only a
small fraction to the total population variance.
 The risk alleles identified to date are also associated with
other mental disorders [bipolar disorder, depression, and
autism spectrum disorder].
 Pregnancy and birth complications with hypoxia and
greater paternal age are associated with a higher risk of
schizophrenia for the developing fetus.
 Other prenatal and perinatal adversities have been linked
with schizophrenia
 Stress
 Infection
 Malnutrition
 Maternal diabetes
 Other medical conditions
 However, the vast majority of offspring with these risk
factors do not develop schizophrenia.
CULTURE-RELATED DIAGNOSTIC ISSUES
Cultural Relativism
 Ideas that appear to be delusional in one culture may be
commonly held in another [e.g. witchcraft]
 Assessment of affect requires sensitivity to differences in
styles of emotional expression, eye contact & body
language, w/c vary across cultures
 Distress may take the form of hallucinations or pseudo-
hallucinations
 Overvalued ideas that may present clinically similar to true
psychosis but are actually normative to the patient's
subgroup.
 Visual or auditory hallucinations with a religious content
are a normal part of religious experience. [e.g. hearing
God's voice]
Linguistic Barrier
 Assessment of disorganized speech may be made difficult
by linguistic variation in narrative styles across cultures.
 The assessment is conducted in a language that is
different from the individual's primary language, care must
be taken to ensure that alogia is not related to linguistic
barriers.
GENDER RELATED DIAGNOSTIC ISSUES
 General incidence of schizophrenia tends to be slightly
lower in females, particularly among treated cases.
 Age at onset is later in females, with a second mid-life
peak.
 Symptoms tend to be more affect-laden among females,
and there are more psychotic symptoms, as well as a
greater propensity for psychotic symptoms to worsen in
later life.
 Other symptom differences include less frequent negative
symptoms and disorganization.
 Social functioning tends to remain better preserved in
females.
VIOLENCE, SUICIDE, AND HOMICIDE
VIOLENCE
Violent behavior (excluding homicide) is common among
untreated schizophrenia patients.
Risk factors:
 Delusions of a persecutory nature
 Previous episodes of violence
 Neurological deficits
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
Management:
Appropriate antipsychotic medication.
Emergency treatment: restraints & seclusion
Acute sedation:
- Lorazepam (Ativan), 1-2 mg IM
- repeated every hour as needed, may be necessary to prevent
the patient from harming others.
SUICIDE
 Approx. 5%-6% die by suicide
 About 20% attempt suicide on one or more occasions
 Many more have significant suicidal ideation.
 Suicidal behavior is sometimes in response to
command hallucinations to harm oneself or others.
 Single leading cause of premature death among people
with schizophrenia.
 Often occur “out of the blue,”• without prior warnings or
expressions of verbal intent
 Most important factor is the presence of a major
depressive episode.
 Patients with the best prognosis (few negative symptoms,
preservation of capacity to experience affects, better
abstract thinking) can paradoxically also be at highest.
Profile of the patient at greatest risk:
 Young man who once had high expectations,
 Declined from a higher level of functioning
 Realizes that his dreams are not likely to come true
 Has lost faith in the effectiveness of treatment.
 Period after a psychotic episode or hospital discharge
Clozapine (Clozaril)
al ideation in
schizophrenia patients with prior hospitalizations for suicidality.
Adjunctive antidepressant medications have been shown to
be effective in alleviating co-occurring major depression in
schizophrenia.
HOMICIDE
Predictors of homicidal tendencies are:
 Patients with violent hallucinations
 With history of violence
 Those who are dangerous
FUNCTIONAL CONSEQUENCES
Significant Social and Occupational Dysfunction
 Making educational progress and maintaining employment
are frequently impaired by avolition or other disorder
manifestations
 Even when the cognitive skills are sufficient for the tasks
at hand.
 Most are employed at lower level than their parents
 Most, particularly men, do not marry or have limited social
contacts outside of their family.
PSYCHOLOGICAL TESTING
NEUROPSYCHOLOGICAL TEST
 Patients with schizophrenia generally perform poorly on a
wide range of neuropsychological tests.
Most affected:
 Vigilance, memory, and concept formation which is
consistent with pathological involvement in the
frontotemporal cortex.
Objective measures of neuropsychiatric performance:
 Halstead-Reitan battery
 Luria-Nebraska battery
 Often give abnormal findings, such as bilateral frontal
and temporal lobe dysfunction, including impairments in
attention, retention time, and problem-solving ability.
 Motor ability is also impaired, possibly related to brain
asymmetry.
INTELLIGENCE TESTS
 Schizophrenia patients tend to score lower on intelligence
tests.
 Low intelligence is often present at the onset, and
intelligence may continue to deteriorate with the
progression of the disorder.
PROJECTIVE AND PERSONALITY TESTS
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1.1
 Projective tests, such as the Rorschach test and the
Thematic Apperception Test, may indicate bizarre
ideation.
 Personality inventories, such as the Minnesota Multiphasic
Personality Inventory, often give abnormal results in
schizophrenia, but the contribution to diagnosis and
treatment planning is minimal.
MENTAL STATUS EXAMINATION GENERAL
DESCRIPTION
 The appearance of a patient with schizophrenia can range
from that of a completely disheveled, screaming, agitated
person to an obsessively groomed, completely silent, and
immobile person.
 Between these two poles, patients may be talkative and
may exhibit bizarre postures.
 In catatonic stupor, often referred to as catatonia, patients
seem completely lifeless and may exhibit such signs as
muteness, negativism, and automatic obedience.
 Waxy flexibility, once a common sign in catatonia, has
become rare, as has manneristic behavior.
 A person with a less extreme subtype of catatonia may
show marked social withdrawal and egocentricity, lack of
spontaneous speech or movement, and an absence of
goal-directed behavior.
 Patients with catatonia may sit immobile and speechless
in their chairs, respond to questions with only short
answers, and move only when directed to move.
PRAECOX FEELING
rapport with a patient.
MOODS, FEELINGS AND AFFECT
Two common affective symptoms in schizophrenia are:
 Reduced emotional responsiveness,
Sometimes severe enough to warrant the label of
anhedonia
 Overly active and inappropriate emotions
Such as extremes of rage, happiness, and anxiety. A flat
or blunted affect can be a symptom of the illness itself, of the
parkinsonian adverse effects of antipsychotic medications, or
of depression, and differentiating these symptoms can be a
clinical challenge.
Overly emotional patients may describe exultant feelings
of omnipotence, religious ecstasy, terror at the disintegration of
their souls, or paralyzing anxiety about the destruction of the
universe.
Other feeling tones include perplexity, a sense of isolation,
overwhelming ambivalence, and depression.
PERCEPTUAL DISTURBANCES
Halucinations
Auditory hallucinations (most common)
Tactile, olfactory, and gustatory hallucinations
underlying medical or neurological d/o)
Cenesthetic Hallucinations
Unfounded sensations of altered states in bodily organs.
- burning sensation in the brain
- pushing sensation in the blood vessels
- cutting sensation in the bone marrow
Illusions
Can occur in schizophrenia patients during active phases, but
they can also occur during the prodromal phases and during
periods of remission.
NOTE: Whenever illusions or hallucinations occur, clinicians
should consider the possibility of a substance-related cause for
the symptoms, even when patients have already received a
diagnosis of schizophrenia.
DISORDERS OF THOUGHT
Most difficult symptoms to understand, but they may be the
core symptoms of schizophrenia
 THOUGHT CONTENT
Disorders of thought content reflect the patient's ideas,
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 PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders 1.1

beliefs, and interpretations of stimuli. recognized in schizophrenia

 LOSS OF EGO BOUNDARIES  Rates of obsessive-compulsive disorder and panic
Describes the lack of a clear sense of where the patient's disorder are elevated in individuals with schizophrenia
own body, mind, and influence end and where those of other compared with general population.
animate and inanimate objects begin. For example:  Schizotypal or paranoid personality disorder may
 IDEAS OF REFERENCE sometimes precede the onset of schizophrenia.
Patients may thnk that other persons, the television, or the Medical Comorbidities
newspapers are referring to them.  Life expectancy is reduced in individuals with
 schizophrenia because of associated medical conditions.
Sense that the patient has physically fused with an outside  Medical conditions that are more common in
object (e.g., a tree or another person) or that the patient has schizophrenia:
disintegrated and fused with the entire universe  Weight gain
 FORM OF THOUGHT  Diabetes
Looseness of associations  Metabolic syndrome
 Derailment  Cardiovascular disease
 Incoherence  Pulmonary disease
 Tangentiality  Poor engagement in health maintenance behaviors (e.g.,
 Circumstantiality cancer screening, exercise) increases the risk of chronic
 Neologisms disease
 Echolalia  Other disorder factors, including medications, lifestyle,
 Verbigeration cigarette smoking, and diet, may also play a role.
 Word salad  A shared vulnerability for psychosis and medical disorders
 Mutism. may explain some of the medical comorbidity of
 THOUGHT PROCESS schizophrenia.
Concern the way ideas and languages are formulated.
Disorder inferred from what and how the patient speaks, Neurological Findings
writes, or draws. Hard signs: Localizing neurological signs
Include: Soft signs: nonlocalizing neurological signs include
 Flight of ideas dysdiadochokinesia, astereognosis, primitive reflexes, and
 Thought blocking diminished dexterity.
 Impaired attention (+) neurological S/Sxs correlates with increased severity of
 Poverty of thought content illness, affective blunting, and a poor prognosis.
 Poor abstraction abilities Other abnormal neurological signs include:
 Perseveration  Tics
 Idiosyncratic associations (e.g., identical predicates,  Stereotypies
clang associations)  Grimacing
 Over inclusion  Impaired fine motor skills
 Circumstantiality.  Abnormal motor tone
 Thought Control - outside forces are controlling what  Abnormal movements.
the patient thinks or feels
 Thought Broadcasting -patients think others can read  Only about 25 percent of patients with schizophrenia are
their minds or that their thoughts are broadcast aware of their own abnormal involuntary movements and
through television sets or radios. that the lack of awareness (Anosognosia) is correlated
with lack of insight about the primary psychiatric disorder
and the duration of illness.
SENSORIUM AND COGNITION
Orientation Eye Examination
 Patients with schizophrenia are usually oriented to person,  Saccadic movement - Disorder of smooth ocular pursuit
time, and place.  Elevated blink rate - reflects hyperdopaminergic activity
Memory Speech
 Memory is usually intact, but there can be minor cognitive  Disorders of speech in schizophrenia (e.g., looseness of
deficiencies. associations) may also indicate a forme fruste of aphasia,
perhaps implicating the dominant parietal lobe.
Cognitive Impairment
 Inability of schizophrenia patients to perceive the prosody
 In outpatients, cognitive impairment is a better predictor of of speech or to inflect their own speech can be seen as a
level of function than is the severity of psychotic neurological symptom of a disorder in the nondominant
symptoms. Patients with schizophrenia typically exhibit parietal lobe.
subtle cognitive dysfunction in the domains of attention,
 Other parietal lobe-like symptoms in schizophrenia
executive function, working memory, and episodic
include:
memory.
 Inability to carry out tasks (i.e., apraxia)
Judgment and Insight  right-left disorientation
 lack of concern about the disorder.
 Patients with schizophrenia are described as having poor
insight into the nature and the severity of their disorder,
Other Comorbidity
associated with poor compliance with treatment.

Reliability  This is due, at least in part, to the effect of many

 A patient with schizophrenia is no less reliable than any
other psychiatric patient. Nature of the disorder, however,
requires the examiner to verify important information
through additional sources.
COMORBIDITY
Comorbidity with other Psychiatric Condition
 Comorbidity with substance-related disorders
 High rates in schizophrenia
 Over half of individuals with schizophrenia have tobacco
use disorder & smoke cigarettes regularly
 Comorbidity with anxiety disorders, increasingly
antipsychotic medications, as well as poor nutritional
balance and decreased motor activity.
 Schizophrenia is associated with an increased risk of
type II diabetes mellitus.
iovascular Disease
 Many antipsychotic medications have direct effects on
cardiac electrophysiology.
 In addition, obesity, increased rates of smoking,
diabetes, hyperlipidemia, and a sedentary lifestyle all
independently increase the risk of cardiovascular
morbidity and mortality.

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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
 Patients with schizophrenia appear to have a risk of
HIV infection that is 1.5 to 2 times that of the general
population.
 Rates of COPD are reportedly increased in
schizophrenia compared to the general population.
Patients with schizophrenia have approximately 1/3 risk of RA
that is found in the general population.
DIFFERERENTIAL DIAGNOSIS
MAJOR DEPRESSIVE OR BIPOLAR DISORDER WITH
PSYCHOTIC OR CATATONIC FEATURES
 If delusions or hallucinations occur exclusively during
a major depressive or manic episode, the diagnosis is
depressive or bipolar disorder with psychotic features.
SCHIZOAFFECTIVE DISORDER
 A diagnosis of schizoaffective disorder requires that a
major depressive or manic episode occur
concurrently with the active-phase symptoms and that
the mood symptoms be present for a majority of the
total duration of the active periods.
SCHIZOPHRENIFORM DISORDER AND BRIEF PSYCHOTIC
DISORDER
 These are of shorter duration than schizophrenia (which
requires 6 months of symptoms).
 Schizophreniform disorder, the disturbance is present
less than 6 months
 Brief psychotic disorder, symptoms are present at least
1 day but less than 1 month
DELUSIONAL DISORDER
 Can be distinguished from schizophrenia by the absence
of the other symptoms characteristic of
schizophrenia:
 Delusions
 Prominent auditory or visual hallucinations
 Disorganized speech
 Grossly disorganized or catatonic behavior
 Negative symptoms
SCHIZOTYPAL PERSONALITY DISORDER
 Schizotypal personality disorder may be distinguished
from schizophrenia by subthreshold symptoms that are
associated with persistent personality features.
OBSESSIVE-COMPULSIVE DISORDER AND BODY
DYSMORPHIC DISORDER
 Individuals with obsessive-compulsive disorder and body
dysmorphic disorder may present with:
 Poor or absent insight
 Preoccupations may reach delusional proportions
 These disorders are distinguished from schizophrenia by
their prominent:
 Obsessions
 Compulsions
 Preoccupations with appearance or body odor
 Hoarding
 Body-focused repetitive behaviours
POSTTRAUMATIC STRESS DISORDER
 Flashbacks that have a hallucinatory quality
 Hypervigilance that may reach paranoid proportions
 But a traumatic event and characteristic symptom features
relating to reliving or reacting to the event are required
to make the diagnosis.
AUTISM SPECTRUM DISORDER OR COMMUNICATION
DISORDERS
 Distinguished by their respective deficits in social
interaction with repetitive and restricted behaviors and
other cognitive and communication deficits.
 neuropathological, and neurophysiological research has
communication disorder must have symptoms that
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1.1
SCHIZOPHRENIFORM
DIAGNOSTIC CRITERIA
A. Two (or more) of the following, each present for a
significant portion of time during a 1-month period (or less if
successfully treated).
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (e.g., diminished emotional
expression or avolition
B. An episode of the disorder lasts at least 1 month but less
than 6 months.
o When the diagnosis must be made without waiting for
recovery it should be qualifies as “provisional.”
C. Schizoaffective disorder and depressive or bipolar disorder
with psychotic features have been ruled out because
o no major depressive or manic episodes have occurred
concurrently with the active-phase symptoms, or
o if mood episodes have occurred during active-phase
symptoms, they have been present for a minority of the
total duration of the active and residual periods of the
illness.
D. The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication)
or another medical condition.
Specify if:
 With good prognostic features: This specifier requires the
presence of at least two of the following features:
o onset of prominent psychotic symptoms within 4 weeks
of the first noticeable change in usual behavior or
functioning;
o confusion or perplexity: good premorbid social and
occupational functioning; and
o absence of blunted or flat affect.
 Without good prognostic features: This specifier is
applied if two or more of the above features have not been
present.
Specify if
 with catatonia
Specify current severity:
 Severity is rated by a quantitative assessment of the primary
symptoms (same as in Brief Psychotic Disorder)
DIAGNOSTIC FEATURES
The diagnosis of schizophreniform disorder is made under two
conditions.
1) An episode of illness lasts between 1 and 6 months
and the individual has already recovered, and
2) Individual is symptomatic for less than the 6
months' duration required for the diagnosis of
schizophrenia but has not yet recovered.
 In this case, the diagnosis should be noted as
"schizophreniform disorder (provisional)" because it is
uncertain if the individual will recover from the disturbance
within the 6-month period.
 If the disturbance persists beyond 6 months, the diagnosis
should be changed to schizophrenia.
 Another distinguishing feature of schizophreniform
disorder is the lack of a criterion requiring impaired
social and occupational functioning.
 While such impairments may potentially be present, they
are not necessary for its diagnosis.
 In addition to the five symptom domain areas identified in
the diagnostic criteria, the assessment of cognition,
depression, and mania symptom domains is vital for
making critically important distinctions between the various
schizophrenia spectrum and other psychotic disorders
ASSOCIATED FEATURES SUPPORTING DIAGNOSIS
 No laboratory or psychometric tests for schizophreniform
disorder.
 There are multiple brain regions where neuroimaging,
indicated abnormalities, but none are diagnostic
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
Brain Imaging
 Relative activation deficit in the inferior prefrontal region
of the brain while performing a region-specific
psychological task of Wisconsin Card Sorting Test.
 Some study showed impaired striatal activity
suppression limited to the left hemisphere
PREVALENCE AND EPIDEMIOLOGY
Prevalence
 Incidence: similar to that observed in schizophrenia.
 In US and other developed countries, incidence is low
(fivefold less than that of schizophrenia).
 In developing countries, incidence may be higher, esp. for
specifier ''with good prognostic features";
 In some of these settings schizophreniform disorder may
be as common as schizophrenia.
Epidemiology
 Most common in adolescents and young adults
 Less than half as common as schizophrenia
DEVELOPMENT AND COURSE
 Development is similar to that of schizophrenia.
 About 1/3 of individuals with an initial diagnosis of
schizophreniform disorder (provisional) recover within 6-
month period and schizophreniform disorder is their final
diagnosis.
 Majority of the remaining 2/3 will receive a diagnosis of
schizophrenia/schizoaffective d/o.
Clinical features
 Favorable course: presence of affective symptoms
 Unfavorable course: flat or blunt affect
RISK AND PROGNOSTIC FACTORS
 Genetic and physiological
 Relatives of individuals with schizophreniform disorder
have an increased risk for schizophrenia.
FUNCTIONAL CONSEQUENCES OF SCHIZOPHRENIFORM
DISORDER
 Majority who eventually receive a diagnosis of
schizophrenia or schizoaffective disorder, have similar
functional consequences of those disorders.
 Most experience dysfunction in several areas of daily
functioning, such as school or work, interpersonal
relationships, and self-care.
better functional outcomes.
 (fivefold less than that of schizophrenia).
 In developing countries, incidence may be higher, esp. for
specifier ''with good prognostic features";
 In some of these settings schizophreniform disorder may
be as common as schizophrenia.
BRIEF PSYCHOTIC DISORDER
DIAGNOSTIC CRITERIA
A. Presence of one (or more) of the following symptoms. At
least one of there (1), (2), (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or
incoherence)
4. Grossly disorganized or catatonic behavior
Note: Do not include a symptom if it is a culturally sanctioned
response
B. Duration of an episode of the disturbance is at least 1 day
but less than 1 month, with eventual full return to premorbid
level of functioning.
C. The disturbance is not better explained by major depressive
or bipolar disorder w/ psychotic features or another
psychotic disorder such as schizophrenia or catatonia
o not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or
another medical condition
Specify if:
o With marked stressor(s) (brief reactive psychosis):
 Symptoms occur in response to events that, singly or
ARBOLEDA, Leigh | PAMPLONA, Hosanne | SENA, Gab | WONG, Anjeh
1.1
together, would be markedly stressful to almost
anyone in similar circumstance in the individual’s
culture
o Without marked stressor(s)
 Symptoms do not occur in response to events that,
singly or together, would be markedly stressful to
almost anyone in similar circumstance in the
individual’s culture.
o With postpartum onset
 Onset is during pregnancy or 4 weeks postpartum
Specify if with catatonia (refer to the criteria for catatonia
associated with other mental disorder)
Specify current severity:
o Rated by rated by a quantitative assessment of the
primary symptoms of psychosis, including delusions,
hallucinations, disorganized speech, abnormal
psychomotor behavior, and negative symptoms
o Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point
scale ranging from 0 (not present) to 4 (present and
severe)
DIAGNOTIC FEATURE
 Brief psychotic disorder is an acute and transient
psychotic syndrome
 Psychotic symptoms last at least 1 day but less than 1
month
 Not associated with a mood disorder, a substance-related
disorder, or a psychotic disorder caused by a general
medical condition.
 There are three subtypes of brief psychotic disorder:
(1) The presence of a stressor,
(2) The absence of a stressor, and
(3) A postpartum onset.
ASSOCIATED FEATURES SUPPORTING DIAGNOSIS
 Typically experience emotional turmoil or overwhelming
confusion.
 Although disturbance is brief, level of impairment may be severe
o Supervision may be required to ensure that nutritional and
hygienic needs are met
 Increased risk of suicidal behavior particularly during the acute
episode
CLINICAL FEATURES
 No negative symptoms (doc Joge)
 An abrupt onset, but do not always include the entire
symptom pattern seen in schizophrenia.
 Some clinicians have observed that labile mood,
confusion, and impaired attention
 Characteristic symptoms include:
o Emotional volatility
o Strange or bizarre behaviour
o Screaming or muteness
o Impaired memory of recent events
 Scandinavian and other European literature include acute
paranoid reactions and reactive confusion, excitation,
and depression.
 Some data suggest that, in the United States, paranoia is
often the predominant symptom in the disorder.
 In French psychiatry, bouffée délirante is similar to brief
psychotic disorder.
o Bouffée délirante reactions are sudden attacks of brief
duration with paranoid delusions and often concomitant
hallucinations, typically precipitated by an intense fear of
magical persecution through sorcery or witchcraft
PRECIPITATING STRESSORS
 The clearest examples of precipitating stressors are major
life events that would cause any person significant
emotional upset.
o Such events include the loss of a close family
member or a severe automobile accident.
o Some clinicians argue that the severity of the event
must be considered in relation to the patient’s life.
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
 Others have argued that the stressor may be a series of
modestly stressful events rather than a single markedly
stressful event
EPIDEMIOLOGY
 Considered uncommon
 More often in
o younger (20s and 30s) than in older patients
o women than in men
o low socioeconomic status
o those who have experience disaster or major cultural
changes (immigrants)
 The age of onset in industrialized settings may be higher
than in developing countries.
 Persons who have gone through major psychosocial
stressors may be at greater risk for subsequent brief
psychotic disorder
ETIOLOGY
 The cause of brief psychotic disorder is unknown.
 Patients who have a personality disorder may have a
biological or psychological vulnerability for the
development of psychotic symptoms, particularly those
with borderline, schizoid, schizotypal, or paranoid
qualities.
o Some have a history of schizophrenia or mood
disorders in their families
 Psychodynamic formulations have emphasized the
presence of inadequate coping mechanisms and the
possibility of secondary gain for patients with psychotic
symptoms.
 Additional psychodynamic theories suggest that the
psychotic symptoms are a defense against:
o a prohibited fantasy,
o the fulfillment of an unattained wish, or
o an escape from a stressful psychosocial situation
COURSE AND PROGNOSIS
 The course of brief psychotic disorder is less than 1
month.
 Approximately half of patients who are first classified as
having brief psychotic disorder later display chronic
psychiatric syndromes such as schizophrenia and mood
disorders.
 Patients with brief psychotic disorder generally have good
prognoses
o 50 to 80%of all patients have no further major
psychiatric problems
 The length of the acute and residual symptoms is often
just a few days.
 Occasionally, depressive symptoms follow the resolution
of the psychotic symptoms.
 Suicide is a concern during both the psychotic phase and
the post psychotic depressive phase.
COMORBIDITY
 Often seen in patients with personality disorders (most
commonly:
o histrionic o schizotypal
o narcissistic o borderline personality disorders
o paranoid
Good Prognostic Features for Brief Psychotic Disorder
 Good premorbid adjustment
 Few premorbid schizoid traits
 Severe precipitating stressor
 Sudden onset of symptoms
 Affective symptoms
 Confusion and perplexity during psychosis
 Little affective blunting
 Short duration of symptoms
 Absence of schizophrenic relatives
DEVELOPMENT AND COURSE
 May appear in adolescence or early adulthood
 Onset can occur across the lifespan
o Average age at onset: mid 30s
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1.1
 Diagnosis of brief psychotic disorder requires a full remission of
all symptoms and an eventual full return to the premorbid level of
functioning w/in 1 month of onset of disturbance
 In some, duration of psychotic symptoms may be brief (few days)
RISK AND PROGNOSTIC FACTORS
 Temperamental
o Preexisting personality disorders and traits may predispose the
individual to the development of the disorder
 Schizotypal personality disorder
 Borderline personality disorder
 Traits in the psychoticism domain
- Perceptual dysregulation
- Negative affectivity (e.g. suspiciousness)
CULTURE RELATED DIAGNOSTIC ISSUES
 It is important to distinguish symptoms of brief psychotic disorder
from culturally sanctioned response patterns
o An individual may report hearing voices in some religious
ceremonies but are not perceived as abnormal by most
members of the individual’s community
 Cultural and religious background must be taken into account
when considering whether beliefs are delusional
FUNCTIONAL CONSEQUENCES OF BRIEF PSYCHOTIC
DISORDER
 Despite high rates of relapse, for most individuals, outcome is
excellent in terms of social functioning and symptomatology.
DIFFERENTIAL DIAGNOSIS
 If psychotic symptoms are present longer than 1 month,
the diagnoses of:
o schizophreniform disorder
o schizoaffective disorder
o schizophrenia
o mood disorders with psychotic features
o delusional disorder
o psychotic disorder not otherwise specified
 In factitious disorder, symptoms are intentionally
produced;
 In malingering, a specific goal is involved in appearing
psychotic (e.g., to gain admission to the hospital)
 When associated with a medical condition or drugs,
the cause becomes apparent with proper medical or drug
workups.
 Patients with epilepsy or delirium can also show psychotic
symptoms that resemble those seen in brief psychotic
disorder.
 Additional psychiatric disorders to be considered in the
differential diagnosis include dissociative identity
disorder and psychotic episodes associated with
borderline and schizotypal personality disorders.
 Other medical conditions
o Psychotic disorder due to another medical condition or
delirium is diagnosed when there is evidence (from history,
PE, laboratory tests) that the delusions/hallucinations are
direct physiological consequence of a specific medical
condition (e.g., Cushing’s syndrome)
 Substance-related disorders
o distinguished from brief psychotic disorder by the fact that a
substance (e.g., a drug of abuse, a medication, exposure to a
toxin) is judged to be etiologically related to the psychotic
symptoms
o Laboratory tests (a urine drug screen or a blood alcohol level)
may be helpful
o Careful history of substance use with attention to temporal
relationships between substance intake and onset of the
symptoms and to the nature of the substance being used.
 Depressive and bipolar disorders
o Diagnosis of brief psychotic disorder cannot be made if
psychotic symptoms are better explained by a mood episode
(i.e., the psychotic symptoms occur exclusively during a full
major depressive, manic, or mixed episode).
 Other psychotic disorders
o The differential diagnosis between brief psychotic disorder
and schizophreniform disorder is difficult when the psychotic
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
symptoms have remitted before 1 month in response to
successful treatment with medication.
o Careful attention should be given to the possibility that a
recurrent disorder (e.g., bipolar disorder, recurrent acute
exacerbations of schizophrenia) may be responsible for any
recurring psychotic episodes.
 Personality disorders
o Psychosocial stressors may precipitate brief periods of
psychotic symptoms.
o These symptoms are usually transient and do not warrant a
separate diagnosis.
o If psychotic symptoms persist for at least 1 day, an additional
diagnosis of brief psychotic disorder may be appropriate.
SCHIZOAFFECTIVE DISORDER
DIAGNOSTIC CRITERIA
A. An uninterrupted period of illness during which there is a
major mood episode (major depressive or manic)
concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1:
Depressed mood
B. Delusions or hallucinations for 2 or more weeks in the
absence of a major mood episode (depressive or manic)
during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are
present for the majority of the total duration of the active
and residual portions of the illness.
D. The disturbance is not attributable to the effects of a
substance (e.g., a drug of abuse, a medication) or another
medical condition.
Specify whether:
o Bipolar type: This subtype applies if a manic episode is
part of the presentation.
 Major depressive episodes may also occur.
o Depressive type: This subtype applies if only major
depressive episodes are part of the presentation.
Specify if with catatonia (refer to the criteria for catatonia
associated with other mental disorder)
 Coding note: use additional code catatonia associated
with brief psychotic disorder to indicate the presence of
comorbid catatonia
Specify if:
 The following course specifiers are only to be used after a 1
-year duration of the disorder and if they are not in
contradiction to the diagnostic course criteria.
 First episode, currently in acute episode:
 First manifestation of the disorder meeting the
defining diagnostic symptom and time criteria.
 An acute episode is a time period in which the
symptom criteria are fulfilled.
 First episode, currently in partial remission:
 Partial remission is a time period during which an
improvement after a previous episode is
maintained
 The time period in which the defining criteria of the
disorder are only partially fulfilled.
 First episode, currently in full remission:
 Full remission is a period of time after a previous
episode during which no disorder-specific
symptoms are present.
 Multiple episodes, currently in acute episode:
 Multiple episodes may be determined after a
minimum of two episodes (i.e., after a first
episode, a remission and a minimum of one
relapse)
 Multiple episodes, currently in partial remission
 Multiple episodes, currently in full remission
 Continuous:
 Symptoms fulfilling the diagnostic symptom criteria
of the disorder are remaining for the majority of
the illness course
 With subthreshold symptom periods being very
brief relative to the overall course.
 Unspecified
Specify current severity:
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1.1
 Severity is rated by a quantitative assessment of the primary
symptoms of psychosis inclusing:
o Delusions
o Hallucinations
o Disorganized speech
o Abnormal psychomotor behaviour
o Negative symptoms
 Each of these symptoms may be rated for its current
severity
o most severe in the last 7 days
o on a 5-point scale ranging from 0 to 4
 0 (not present)
 4 (present and severe)
CLINICAL FEATURE
 Schizoaffective disorder has features of both
schizophrenia and mood disorders.
 Patients can receive the diagnosis of schizoaffective
disorder if they fit into one of the following six categories:
(1) With schizophrenia who have mood symptoms
(2) With mood disorder who have symptoms of
schizophrenia
(3) With both mood disorder and schizophrenia
(4) With a third psychosis unrelated to schizophrenia and
mood disorder
(5) Whose disorder is on a continuum between
schizophrenia and mood disorder
(6) With some combination of the above
 The length of each episode is critical for two reasons:
o To meet the Criterion B (psychotic symptoms in the
absence of a major mood episode [depressive or
manic]),
 it is important to know when the affective episode
ends and the psychosis continues.
o To meet Criterion C, the length of all mood
episodes must be combined and compared with
the total length of the illness.
 If the mood component is present for the majority
(>50%) of the total illness, then that criterion is
met.
DIAGNOSTIC FEATURES
 Diagnosis of schizoaffective disorder is based on the assessment
of an uninterrupted period of illness
o during which the individual continues to display active or
residual symptoms of psychotic illness.
 The diagnosis is usually, but not necessarily, made during the
period of psychotic illness.
 At some time during the period. Criterion A for schizophrenia
has to be met.
o Criteria B (social dysfunction) and F (exclusion of autism
spectrum disorder or other commimication disorder of
childhood onset) for schizophrenia do not have to be met.
 Loss of interest or pleasure is common in schizophrenia, to meet
Criterion A for schizoaffective disorder, the major depressive
episode must include pervasive depressed mood
 i.e. the presence of markedly diminished interest or pleasure
is not sufficient
 Criterion C requires the assessment of mood symptoms for the
entire course of a psychotic illness
o which differs from the criterion in DSM-IV, which required
only an assessment of the current period of illness.
 If the mood symptoms are present for only a relatively brief
period, diagnosis is schizophrenia
 In addition to the five symptom domain areas identified in the
diagnostic criteria, it is vital to assess:
o Cognition
o Depression
o Mania symptom domains
ASSOCIATED FEATURES SUPPORTING DIAGNOSIS
 Impaired occupational functioning
o but this is not a defining criterion for schizoaffective d/o
 Restricted social contact and difficulties with self-care
o but negative symptoms may be less severe and less persistent
than those seen in schizophrenia.
 Anosognosia (poor insight) - common
o but the deficits in insight may be less severe and pervasive
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
than those in schizophrenia.
 Increased risk for later developing episodes of major depressive
disorder or bipolar disorder
 Alcohol and other substance-related disorders
EPIDEMIOLOGY
 Lifetime prevalence of less than 1%: 0.5-0.8%
 In practice, it is used as a preliminary dx when physician is
uncertain.
GENDER AND AGE DIFFERENCE
 Generally parallel sex differences seen in mood disorders
o Equal numbers of men and women who have the
bipolar subtype
o More than twofold female to male predominance
among individuals with the depressed subtype of
schizoaffective disorder
 The depressive type may be more common in older
persons than in younger persons
 The bipolar type may be more common in young adults
than in older adults.
 The age of onset for women is later than that for men
 Men are likely to exhibit antisocial behaviour and to have a
markedly flat or inappropriate affect.
 About one-third as common as schizophrenia.
 Lifetime prevalence: 0.3%
 Incidence is higher in females than in males
o Mainly due to an increased incidence of the depressive type
among females.
COMORBIDITY
 Many individuals diagnosed with schizoaffective disorder are
also diagnosed with other mental disorders especially:
o substance use disorders
o anxiety disorders
 Similarly, the incidence of medical conditions is increased above
base rate for the general population and leads to decreased life
expectancy
ETIOLOGY
 Cause unknown.
 May be a type of:
o Schizophrenia
o Mood disorder
o The simultaneous expression of each
 May also be a distinct 3rd type of psychosis
o One that is unrelated to schizo or mood d/o.
 A heterogeneous group of d/o encompassing all of the
above possibilities.
 Studies of the disrupted in schizophrenia 1 (DISC1) gene,
located on chromosome 1q42, suggest its possible
involvement in schizoaffective disorder as well as
schizophrenia and bipolar disorder.
 Patients prognosis :
o Better that schizo, worse than mood d/o
o Mood d/o > Schizoaffective > Schizophrenia
 Have nondeteriorating course and respond better to
lithium than schizo
Genetic and physiological
 The risk for schizoaffective disorder may be increased among
individuals who have a first-degree relative with:
o Schizophrenia
o Bipolar disorder
o Schizoaffective disorder
COURSE AND PROGNOSIS
 It has been presumed that an increasing presence of
schizophrenic symptoms predicted a worse prognosis.
 Predominant symptoms were affective (better prognosis)
or schizophrenic (worse prognosis).
 One study that followed patients diagnosed with
schizoaffective disorder for 8 years found that the
outcomes of these patients more closely resembled
schizophrenia than mood disorder with psychotic features.
ARBOLEDA, Leigh | PAMPLONA, Hosanne | SENA, Gab | WONG, Anjeh
1.1
 Typical age at onset: Early adulthood
o Although can occur anywhere from adolescence to late in life.
 May occur in a variety of temporal patterns
 The typical pattern:
o An individual may have pronounced auditory hallucinations
and persecutory delusions for 2 months before the onset of
a prominent major depressive episode.
o The psychotic symptoms and the full major depressive
episode are then present for 3 months.
o Then, the individual recovers completely from the major
depressive episode, but the psychotic symptoms persist for
another month before they too disappear.
o During this period of illness, the individual's symptoms
concurrently met criteria for a major depressive episode and
Criterion A for schizophrenia, and during this same period of
illness, auditory hallucinations and delusions were present
both before and after the depressive phase.
o The total period of illness lasted for about 6 months, with:
 psychotic symptoms alone present during the initial 2
months
 both depressive and psychotic symptoms present during the
next 3 months
 psychotic symptoms alone present during the last month.
o In this instance, duration of depressive episode was not brief
relative to the total duration of the psychotic disturbance
 thus the presentation qualifies for a diagnosis of
schizoaffective disorder.
 The expression of psychotic symptoms across the lifespan is
variable.
 Depressive or manic symptoms can occur before the onset of
psychosis, during:
o acute psychotic episodes
o residual periods
o or after cessation of psychosis.
 Schizoaffective disorder, bipolar type, may be more common in
young adults
o whereas schizoaffective disorder, depressive type, may be
more common in older adults.
DIFFERENTIAL DIAGNOSIS
 To rule out organic causes for the symptoms perform a
complete medical workup
 A history of substance use (with or without positive results
on a toxicology screening test) may indicate a substance-
induced disorder.
 Preexisting medical conditions, their treatment, or both
can cause psychotic and mood disorders.
 Any suspicion of a neurological abnormality warrants
consideration of a brain scan to rule out anatomical
pathology and an electroencephalogram to determine any
possible seizure disorders (e.g., temporal lobe epilepsy).
 Psychotic disorder caused by seizure disorder is more
common than that seen in the general population.
o It tends to be characterized by paranoia,
hallucinations, and ideas of reference.
 Patients with epilepsy with psychosis are believed to have
a better level of function than patients with schizophrenic
spectrum disorders.
o Better control of the seizures can reduce the
psychosis.
Psychiatric and medical conditions that can manifest with
psychotic and mood symptoms:
1. Psychotic disorder due to another medical condition
2. Delirium
3. Major neurocognitive disorder
4. Substance/medication-induced psychotic disorder or
neurocognitive disorder
5. Bipolar disorders with psychotic features
6. Major depressive disorder with psychotic features
7. Depressive or bipolar disorders with catatonic features
8. Schizotypal, schizoid, or paranoid personality disorder
9. Brief psychotic disorder
10. Schizophreniform disorder
11. Schizophrenia
12. Delusional disorder
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
13. Other specified and unspecified schizophrenia spectrum and
other psychotic disorders
 Medical conditions and substance use can present with a
combination of psychotic and mood symptoms
o thus psychotic disorder due to another medical condition
needs to be excluded.
 Distinguishing schizoaffective disorder from schizophrenia and
from depressive and bipolar disorders with psychotic features
is often difficult.
o Criterion C is designed to separate schizoaffective disorder
from schizophrenia
o Criterion B is designed to distinguish schizoaffective disorder
from a depressive or bipolar disorder with psychotic features.
o More specifically, schizoaffective disorder can be
distinguished from a depressive or bipolar disorder with
psychotic features due to the presence of prominent delusions
and/or hallucinations for at least 2 weeks in the absence of a
major mood episode.
o In contrast, in depressive or bipolar disorders with psychotic
features, the psychotic features primarily occur during the
mood episode(s).
 Because the relative proportion of mood to psychotic symptoms
may change over time, the appropriate diagnosis may change from
and to schizoaffective disorder
o e.g., a diagnosis of schizoaffective disorder for a severe and
prominent major depressive episode lasting 3 months during
the first 6 months of a persistent psychotic illness would be
changed to schizophrenia if active psychotic or prominent
residual symptoms persist over several years without a
recurrence of another mood episode
Psychotic disorder due to another medical condition
 Other medical conditions and substance use can manifest with a
combination of psychotic and mood symptoms
 Psychotic disorder due to another medical condition needs to be
excluded
 Include all possibilities usually considered for mood d/o & for
schizo
 Exclude:
o organic cause
o substance or alcohol abuse
o possible seizure d/o
 temporal lobe epilepsy
 Psychotic d/o due to seizure d/o
o characterized by:
 paranoia
 hallucinations
 ideas of reference
 better control of seizures can reduce psychosis
CULTURE-RELATED DIAGNOSTIC ISSUES
 Cultural & socioeconomic factors must be considered
 There’s some evidence in literature for overdiagnosis of
schizophrenia compared with schizoaffective disorder in African
American & Hispanic populations.
o Care must be taken to ensure a culturally appropriate
evaluation that includes both psychotic and affective
symptoms.
SUICIDE RISK
 5%: lifetime risk of suicide for schizophrenia and schizoaffective
disorder is
 (+) depressive symptoms ~ higher risk for suicide
 Suicide rates: Higher in North American populations than in
European, Eastern European, South American, and Indian
populations of individuals with schizophrenia or schizoaffective
disorder.
FUNTIONAL CONSEQUENCES
 Social and occupational dysfunction
o but dysfunction is not a diagnostic criterion (as it is for
schizophrenia)
o there is substantial variability between individuals diagnosed
with schizoaffective disorder
ARBOLEDA, Leigh | PAMPLONA, Hosanne | SENA, Gab | WONG, Anjeh
1.1
SUBSTANCE/MEDICATION INDUCED PSYCHOTIC
DISORDER
DIAGNOSTIC CRITERIA
A. Presence of one or both of the following symptoms:
1. Delusions.
2. Hallucinations.
B. There is evidence from the history, physical Examination, or
laboratory findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon
after substance intoxication or withdrawal or after
exposure to a medication.
2. The involved substance/medication is capable of
producing the symptoms in Criterion A.
C. The disturbance is not better explained by a psychotic
disorder that is not substance / medication-induced. Such
evidence of an independent psychotic disorder could
include the following:
o The symptoms preceded the onset of the
substance/medication use
o The symptoms persist for a substantial period of time
(e.g., about 1 month) after the cessation of acute
withdrawal or severe intoxication
o There is other evidence of an independent non-
substance/medication-induced psychotic disorder
 e.g., a history of recurrent non-substance/medication-
related episodes
D. The disturbance does not occur exclusively during the
course of a delirium.
E. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
Note: The diagnosis should be made instead of a diagnosis of
substance intoxication or substance withdrawal only when the
symptoms in Criterion A predominate in the clinical picture and
when they are sufficiently severe to warrant clinical attention
Specify if:
 With onset during intoxication:
o If the criteria are met for intoxication with the substance
and the symptoms develop during intoxication.
 With onset during withdrawal:
o If the criteria are met for withdrawal from the substance
and the symptoms develop during, or shortly after,
withdrawal.
Specify current severity:
 Severity is rated by a quantitative assessment of the primary
symptoms of psychosis, including:
o Delusions
o Hallucinations
o Abnormal psychomotor behaviour
o Negative symptoms
 Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point scale
ranging from 0 (not present) to 4 (present and severe).
Note: Diagnosis of substance/medication-induced psychotic
disorder can be made without using this severity specifier
DIAGNOSTIC FEATURES
 Hallucinations that the individual realizes are
substance/medication-induced are not included here and instead
would be diagnosed as substance intoxication or substance
withdrawal with the accompanying specifier "with perceptual
disturbances" – applies to:
o alcohol withdrawal
o cannabis intoxication
o sedative, hypnotic, or anxiolytic withdrawal
o stimulant intoxication
 Distinguished from a primary psychotic disorder by considering
the: onset, course and other factors.
 Arise during or soon after exposure to a medication or after
substance intoxication or withdrawal but can persist for weeks
o whereas primary psychotic disorders may precede the onset of
substance/medication use or may occur during times of
sustained abstinence
o Once initiated, psychotic symptoms may continue as long as
substance/medication use continues.
 Another consideration is the presence of features that are atypical
of a primary psychotic disorder
o e.g., atypical age at onset or course
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders 1.1

 The appearance of delusions de novo in a person older than
35 years without a known history of a primary psychotic
disorder should suggest possibility of a substance/
medication-induced psychotic disorder.
 Even a prior history of a primary psychotic disorder does not rule
out the possibility of a substance/ medication-induced psychotic
disorder.
 In contrast, factors that suggest that the psychotic symptoms are
better accounted for by a primary psychotic disorder include
persistence of psychotic symptoms for a substantial period of time
(i.e., a month or more) after the end of substance intoxication or
acute substance withdrawal or after cessation of medication use; or
a history of prior recurrent primary psychotic disorders.
 Other causes of psychotic symptoms must be considered even in
an individual with substance intoxication or withdrawal, because
substance use problems are not uncommon among individuals
with non-substance/medication-induced psychotic d/o.
 In addition to the five symptom domain areas identified in the
diagnostic criteria, to make critically important decisions between
various schizophrenia spectrum and other psychotic disorders, it is
vital to assess:
o Cognition
o Depression
o Mania symptom domains
episode of psychosis in different settings:
o have substance/medication-induced psychotic disorder
DEVELOPMENT AND COURSE
 The initiation of the disorder may vary considerably with the
substance.
o For example, smoking a high dose of cocaine may produce
psychosis within minutes, whereas days or weeks of high-dose
alcohol or sedative use may be required to produce psychosis.
 Alcohol-induced psychotic disorder, with hallucinations
o usually occurs only after prolonged, heavy ingestion of
alcohol in individuals who have moderate to severe alcohol
use disorder
o hallucinations are generally auditory in nature.
 Psychotic disorders induced by amphetamine and cocaine share
similar clinical features.
o Persecutory delusions may rapidly develop shortly after use
of amphetamine or a similarly acting sympathomimetic.
 The hallucination of bugs or vermin crawling in or under the skin
(formication) can lead to scratching and extensive skin
excoriations.

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS  Cannabis-induced psychotic disorder may develop shortly after
 Psychotic disorders can occur in association with intoxication high-dose cannabis use and usually involves:
with the following classes of substances: o persecutory delusions
o Alcohol o marked anxiety
o Cannabis o emotional lability
o Hallucinogens[Phencyclidine &related substances] o depersonalization
o Inhalants
o Sedatives  The disorder usually remits within a day but in some cases may
o Hypnotics persist for a few days.
o Anxiolytics  May at times persist when the offending agent is removed
o Stimulants [Cocaine] o such that it may be difficult initially to distinguish it from an
o Other (or unknown) substances independent psychotic disorder
 Agents such as amphetamines, phencyclidine, and cocaine have
 Psychotic disorders can occur in association with withdrawal been reported to evoke temporary psychotic states that can
from the following classes of substances: sometimes persist for weeks or longer despite removal of the agent
o Alcohol and treatment with neuroleptic medication.
o Sedatives
o Hypnotics  In later life, polypharmacy for medical conditions and exposure to
o Anxiolytics; medications for parkinsonism, cardiovascular disease, and other
o Other (or unknown) substances medical disorders may be associated with a greater likelihood of
psychosis induced by prescription medications as opposed to
 Some medications reported to evoke psychotic symptoms substances of abuse
include:
o anesthetics and analgesics DIAGNOSTIC MARKERS
o Anticholinergic agents
 With substances for which relevant blood levels are available:
o Anticonvulsants
o Blood alcohol level
o Antihistamines
o Other quantifiable blood levels (e.g. Digoxin)
o Antihypertensive and cardiovascular medications
o the presence of a level consistent with toxicity may increase
o Antimicrobial medications
diagnostic certainty
o Antiparkinsonian medications
o Chemotherapeutic agents
 Cyclosporine & Procarbazine FUNCTIONAL CONSEQUENCES
o Corticosteroids  Typically severely disabling
o Gastrointestinal medications o observed most frequently in emergency rooms
o Muscle relaxants o as individuals are often brought to the acute-care setting when
o Nonsteroidal anti-inflammatory medications (NSAIDs) it occurs
o Other over-the-counter medications  However, the disability is typically self-limited and resolves
 Phenylephrine upon removal of the offending agent
 Pseudoephedrine
o Antidepressant medication DIFFERENTIAL DIAGNOSIS
o Disulfiram  Substance intoxication /substance withdrawal.
o Individuals intoxicated with stimulants, cannabis, the opioid
 Toxins reported to induce psychotic symptoms include: meperidine, or phencyclidine, or those withdrawing from
o Anticholinesterase alcohol or sedatives may experience altered perceptions that
o Organophosphate insecticides they recognize as drug effects.
o Sarin and other nerve gases o If reality testing for these experiences remains intact (i.e., the
o Carbon monoxide individual recognizes that the perception is substance induced
o Carbon dioxide and neither believes in nor acts on it):
o Volatile substances  Diagnosis is not substance/medication-induced psychotic
 Fuel disorder
 Paint  Instead; substance intoxication or substance withdrawal,
with perceptual disturbances
PREVALENCE - e.g., cocaine intoxication, with perceptual disturbances
 Prevalence in general population: unknown  Hallucinogen persisting perception disorder
 Between 7% and 25% of individuals presenting with a first o "Flashback" hallucinations occurring long after the use of
hallucinogens has stopped

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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
 If substance/medication-induced psychotic symptoms occur
exclusively during the course of a delirium, as in severe forms of
alcohol withdrawal,
o the psychotic symptoms are considered to be an associated
feature of the delirium and are not diagnosed separately.
 Delusions in the context of a major or mild neurocognitive
disorder
o Diagnosis is major or mild neurocognitive disorder, with
behavioral disturbance
 Primary psychotic disorder
o Substance/medication-induced psychotic disorder is
distinguished from a primary psychotic disorder by the fact
that a substance is judged to be etiologically related to the
symptoms.
 Psychotic disorder due to another medical condition
o Substance/medication-induced psychotic disorder due to a
prescribed treatment for a mental or medical condition must
have its onset while the individual is receiving the medication
(or during withdrawal, if there is a withdrawal syndrome
associated with the medication)
o Because individuals with medical conditions often take
medications for those conditions, the clinician must consider
the possibility that the psychotic symptoms are caused by the
physiological consequences of the medical condition rather
than the medication, in which case psychotic disorder due to
another medical condition is diagnosed.
o The history often provides the primary basis for such a
judgment.
o At times, a change in the treatment for the medical condition
(e.g., medication substitution or discontinuation) may be
needed to determine empirically for that individual whether
the medication is the causative agent.
o If the clinician has ascertained that the disturbance is
attributable to both a medical condition and substance/
medication use,
 both diagnoses (i.e., psychotic disorder due to another
medical condition and substance/ medication-induced
psychotic disorder) may be given
PSYCHOTIC DISORDER DUE TO ANOTHER MEDICAL
CONDITION
DIAGNOSTIC CRITERIA
A. Prominent hallucinations or delusions.
B. There is evidence from the history, physical examination, or
laboratory findings that the disturbance is the direct
pathophysiological consequence of another medical
condition
C. The disturbance is not better explained by another mental
disorder.
D. The disturbance does not occur exclusively during the
course of a delirium.
E. The disturbance causes clinically significant distress or
impairment in social, occupational,
or other important areas of functioning.
Specify whether:
 With delusions: If delusions are the predominant symptom.
 With hallucinations: If hallucinations are the predominant
symptom.
Specify current severity:
 Severity is rated by a quantitative assessment of the primary
symptoms of psychosis, including delusions, hallucinations,
abnormal psychomotor behavior, and negative symptoms.
o Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point
scale ranging from 0 (not present) to 4 (present and
severe).
Note: Diagnosis of psychotic disorder due to another medical
condition can be made without using this severity specifier.
DIAGNOSIS
 The diagnosis of psychotic disorder due to a general
medical condition is defined by specifying the predominant
symptoms.
 When the diagnosis is used, the medical condition, along
with the predominant symptoms pattern, should be included
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in the diagnosis (e.g., psychotic disorder due to a brain
tumor, with delusions).
 The disorder does not occur exclusively while a patient is
delirious or demented
SPECIFIERS
 In addition to the symptom domain areas identified in the
diagnostic criteria, the assessment of cognition, depression, and
mania symptom domains is vital for making critically important
distinctions between the various schizophrenia spectrum and other
psychotic disorders.
DIAGNOTIC FEATURES
 Hallucinations can occur in any sensory modality (i.e., visual,
olfactory, gustatory, tactile, or auditory), but certain etiological
factors are likely to evoke specific hallucinatory phenomena.
o Olfactory hallucinations are suggestive of temporal lobe
epilepsy.
o Hallucinations may vary from simple and unformed to highly
complex and organized, depending on etiological and
environmental factors.
o Psychotic disorder due to another medical condition is
generally NOT DIAGNOSED if:
 the individual maintains reality testing for the
hallucinations and appreciates that they result from the
medical condition.
 Delusions may have a variety of themes, including somatic,
grandiose, religious, and, most commonly, persecutory.
 On the whole, however, associations between delusions and
particular medical conditions appear to be less specific than is the
case for hallucinations.
 In determining whether the psychotic disturbance is attributable to
another medical condition, the presence of a medical condition
must be identified and considered to be the etiology of the
psychosis through a physiological mechanism.
 Although there are no infallible guidelines for determining
whether the relationship between the psychotic disturbance and
the medical condition is etiological, several considerations
provide some guidance:
o Presence of a temporal association between the onset,
exacerbation, or remission of the medical condition and that
of the psychotic disturbance.
o Presence of features that are atypical for a psychotic disorder
(e.g., atypical age at onset or presence of visual or olfactory
hallucinations).
o Disturbance must also be distinguished from a
substance/medication-induced psychotic disorder or another
mental disorder (e.g., an adjustment disorder).
ASSOCIATED FEATURES SUPPORTING DIAGNOSIS
 The temporal association of the onset or exacerbation of the
medical condition offers the greatest diagnostic certainty that the
delusions or hallucinations are attributable to a medical condition.
 Additional factors may include concomitant treatments for the
underlying medical condition that confer a risk for psychosis
independently, such as steroid treatment for autoimmune
disorders.
PREVALENCE
 Lifetime prevalence: 0.21% to 0.54%.
o individuals >65 y/o have a significantly greater prevalence of
0.74% compared with those in younger age groups.
o Higher prevalence of the disorder in females
 Rates of psychosis also vary according to the underlying medical
condition
 Conditions most commonly associated with psychosis include:
o untreated endocrine and metabolic disorders, autoimmune
disorders (e.g., SLE, N-methyl-D-aspartate (NMDA) receptor
autoimmune encephalitis)
o temporal lobe epilepsy
 Psychosis due to epilepsy has been further differentiated
into ictal, postictal, and interictal psychosis. The most
common of these is postictal psychosis, (2%-7.8% of
epilepsy patients.)
DEVELOPMENT AND COURSE
 Psychotic disorder due to another medical condition may be a
single transient state or it may be recurrent, cycling with
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exacerbations and remissions of the underlying medical condition.
 Although treatment of the underlying medical condition often
results in a resolution of the psychosis, this is not always the case,
and psychotic symptoms may persist long after the medical event
(e.g., psychotic disorder due to focal brain injury).
RISK AND PROGNOSTIC FACTORS
 Course modifiers.
o Identification and treatment of the underlying medical
condition has the greatest impact on course, although
preexisting CNS injury may confer a worse course outcome.
DIAGNOSTIC MARKERS
Diagnosis of psychotic disorder due to another medical condition
depends on the clinical condition of each individual, and the
diagnostic tests will vary according to that condition.
FUNCTIONAL CONSEQUENCES
 Functional disability is typically severe in the context of psychotic
disorder due to another medical condition but will vary
considerably by the type of condition and likely improve with
successful resolution of the condition.
DIFFERENTIAL DIAGNOSIS
 Delirium
o Hallucinations and delusions commonly occur in the context
of a delirium;
o A separate diagnosis of psychotic disorder due to another
medical condition is not given if the disturbance occurs
exclusively during the course of a delirium.
o Delusions in the context of a major or mild neurocognitive
disorder would be diagnosed as major or mild neurocognitive
disorder, with behavioral disturbance.
 Substance/medication-induced psychotic d/o
o Considered if there is evidence of recent or prolonged
substance use (including medications with psychoactive
effects), withdrawal from a substance, or exposure to a toxin
(e.g., LSD [lysergic acid diethylamide] intoxication alcohol
withdrawal)
o Symptoms that occur during or shortly after (i.e., within 4
weeks) of substance intoxication or withdrawal or after
medication use may be especially indicative of a substance-
induced psychotic disorder, depending on the character,
duration, or amount of the substance used.
o If the clinician has ascertained that the disturbance is due to
both a medical condition and substance use, both diagnoses
(i.e., psychotic disorder due to another medical condition and
substance/medication-induced psychotic disorder) can be
given.
 Psychotic disorder
o In psychotic disorders and in depressive or bipolar disorders,
with psychotic features, no specific and direct causative
physiological mechanisms associated with a medical
condition can be demonstrated.
o Late age at onset and the absence of a personal or family
history of schizophrenia or delusional disorder suggest the
need for a thorough assessment to rule out the diagnosis of
psychotic disorder due to another medical condition.
o Auditory hallucinations that involve voices speaking complex
sentences
 more characteristic of schizophrenia than of psychotic
disorder due to a medical condition.
COMORBIDITY
 Psychotic disorder due to another medical condition in those >80
y/o is associated with concurrent major neurocognitive disorder
(dementia).
CATATONIA
CATATONIA ASSOCIATED WITH ANOTHER MENTAL
DISORDER (CATATONIA SPECIFIER)
DIAGNOSITIC CRITERIA
A. The clinical picture is dominated by three (or more) of the
following symptoms:
1. Stupor (i.e., no psychomotor activity; not actively
relating to environment)
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2. Catalepsy (i.e., passive induction of a posture held
against gravity)
3. Waxy flexibility (i.e., slight even resistance to
positioning by examiner)
4. Mutism (i.e., no or very little verbal response [exclude
if known aphasia])
5. Negativism (i.e., opposition or no response to
instructions of external stimuli)
6. Posturing (i.e, spontaneous and active maintenance
of a posture against gravity)
7. Mannerism (i.e, odd, circumstantial caricature of
normal actions)
8. Stereotypy (i.e, repetitive, abnormally frequent, non-
goal directed movements)
9. Agitation, non-influenced by external stimuli
10. Grimacing
11. Echolalia (i.e., mimicking another’s speech)
12. Echopraxia (i.e., mimicking another’s movements)
CLINICAL FEATURES
 Clinical syndrome characterized by striking behavioral
abnormalities that may include motoric immobility or
excitement, profound negativism, or echolalia (mimicry of
speech) or echopraxia (mimicry of movement)
 Diagnosis of catatonic disorder due to a general medical
condition can be made if there is evidence that the
condition is due to the physiological effects of a general
medical condition
 Maybe a sequelae of primary mental disorder, such as
schizophrenia or psychotic depression, or if catatonic
symptoms occur exclusively within the course of delirium
 Features of catatonia is marked psychomotor disturbance
the may involve:
o Decreased Motor Activity:
 Severe (stupor)
 Moderate (catalepsy or waxy flexibility)
o Decreased Engagement During Interview Or
Physical Examination
 Severe (mutism)
 Moderate (negativism)
o Excessive And Peculiar Motor Activity
 Complex (stereotypy)
 Simple (agitation)
 Echopraxia and Echolalia
 Clinical presentation of catatonia can be puzzling, as the
psychomotor disturbance may range from marked
unresponsiveness to marked agitation
 Extreme cases, the same individual may wax and wane
between decreased & excessive motor activity
DIAGNOTIC FEATURES
 Catatonia associated with mental disorder (catatonia specifier)
o May be used when criteria are met for catatonia during the
course of a neurodevelopmental, psychotic, bipolar,
depressive, or other mental disorder
o Catatonia is typically diagnosed in an inpatient setting and
occurs in up to 35% individuals with schizophrenia, but the
majority of cases involve individuals with depressive or
bipolar disorders
o Can also be a side effect of a medication
o Particular attention should be paid to the possibility that the
catatonia is attributable to neuroleptic malignant syndrome
CATATONIC DISORDER DUE TO ANOTHER MEDICAL
CONDITION
DIAGNOSITIC CRITERIA
A. Criterion A in DSM V Criteria for Catatonia Associated
With Another Mental Disorder (Catatonia Specifier)
B. There is evidence from the history, physical examination,
or laboratory findings that the disturbance is the direct
pathophysiological consequence of another medical
condition
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C. The disturbance is not better explained by another mental
disorder (ex. a manic episode)
D. The disturbance does not occur exclusively during the
course of a delirium
E. The disturbance causes clinically significant distress or
impairment in social, occupational or other important area
of functioning
DIAGNOTIC FEATURES
 Essential feature is the presence of catatonia that is judged to be
attributed to the physiological effects of another medical
condition
ASSOCIATED FEATURES SUPPORTING DIAGNOSIS
 Variety of medical conditions may cause catatonia:
o Neurological conditions
 ex. neoplasms, head trauma, cerebrovascular disease,
encephalitis
o Metabolic conditions
 ex. hypercalcemia, hepatic encephalopathy,
homocystinuria, diabetic ketoacidosis
 The associated PE findings, laboratory findings and patterns of
prevalence and onset reflect those of the etiological medical
condition.
DIFFERENTIAL DIAGNOSIS
 A separate diagnosis of catatonic disorder due to another medical
condition is not given if the catatonia occurs exclusively during
the course of a delirium or neuroleptic malignant syndrome.
 If the individual is currently taking neuroleptic medication,
consideration should be given to medication-induced movement
disorders (ex. abnormal positioning may be due to neuroleptic-
induced acute dystonia) or neuroleptic malignant syndrome (ex.
catatonia-like features may be present along with associated vital
sign and/or laboratory abnormalities)
 Catatonic symptoms may be present in any of the following five
psychotic disorders:
o Brief psychotic disorder
o Schizophreniform disorder
o Schizophrenia
o Schizoaffective disorder
o Substance/medication-induced psychotic disorder
 It may also be present in some of neurodevelop-mental disorders
in all of the bipolar and depressive disorders and in other mental
disorder
UNSPECIFIED CATATONIA
DIAGNOSITIC CRITERIA
 Applies to presentations in which symptoms characteristics
of catatonia cause clinically significant distress or
impairment in social, occupational or other medical condition
is unclear, full of criteria for catatonia are not met or there is
insufficient information to make a more specific diagnosis
(ex.in emergency room settings)
EPIDEMIOLOGY
 Catatonia is an uncommon condition
o Mostly seen in advanced primary mood or psychotic
illnesses
 25 to 50% are related to mood disorders (e.g., major
depressive episode, recurrent, with catatonic features)
 10% are associated with schizophrenia.
ETIOLOGY
 Medical conditions that can cause catatonia include:
o Neurological disorders (e.g., nonconvulsive status
epilepticus, and head trauma)
o Infections (e.g., encephalitis)
o Metabolic disturbances (e.g., hepatic encephalopathy,
hyponatremia, and hypercalcemia).
 Medications that can cause catatonia include:
o Corticosteroids
o Immunosuppressants
o Antipsychotic (i.e., neuroleptic) agents. Catatonic
 Symptoms may be seen in extreme forms of neuroleptic-
induced parkinsonism or neuroleptic malignant syndrome,
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o A rare, potentially lifethreatening disorder associated
with fever, autonomic instability, impaired
consciousness, and rigidity.
LABORATORY EXAMINATION
 There are no pathognomonic laboratory findings in
catatonia. The laboratory evaluation should be used to
rule out an underlying medical condition
 Appropriate medical tests may include complete blood
counts, electrolytes, brain imaging and
electroencephalography (if seizures are suspected)
 Serum creatinine phosphokinase, white blood cell count,
and serum transaminases should be noted
DIFFERENTIAL DIAGNOSIS
 Hypoactive delirium, end-stage dementia, and akinetic
mutism, as well as catatonia due to a primary psychiatric
disorder
 It is important to identify cases of catatonia occurring in
the setting of neuroleptic malignant syndrome because the
latter diagnosis can be fatal
 Features suggesting neuroleptic malignant syndrome
include autonomic instability and delirium in addition to
elevated serum creatinine phosphokinase, white blood cell
count, and serum transaminases
OTHER SPECIFIED SCHIZOPHRENIA SPECTRUM AND
OTHER PSYCHOTIC DISORDER
DIAGNOSITIC CRITERIA
 This category applies to presentations in which symptoms
characteristic of a schizophrenia spectrum and other
psychotic disorder that cause clinically significant distress
or impairment in social, occupational, or other important
areas of functioning predominate but do not meet the full
criteria for any of the disorders in the schizophrenia
spectrum and other psychotic disorders diagnostic class.
 This is used in situations in which the clinician chooses to
communicate the specific reason that the presentation
does not meet the criteria for any specific schizophrenia
spectrum and other psychotic disorder.
 This is done by recording “other specified schizophrenia
spectrum and other psychotic disorder” followed by the
specific reason (e.g., “persistent auditory hallucinations”).
 Examples of presentations that can be specified using the
“other specified” designation include the following:
o Persistent auditory hallucinations occurring in the
absence of any other features.
o Delusions with significant overlapping mood
episodes.
 This includes persistent delusions with periods of
overlapping mood episodes that are present for a
substantial portion of the delusional disturbance
(such that the criterion stipulating only brief mood
disturbance in delusional disorder is not met).
o Attenuated psychosis syndrome:
 This syndrome is characterized by psychotic-like
symptoms that are below a threshold for full
psychosis (e.g., the symptoms are less severe
and more transient, and insight is relatively
maintained).
o Delusional symptoms in partner of individual with
delusional disorder:
 In the context of a relationship, the delusional
material from the dominant partner provides
content for delusional belief by the individual who
may not otherwise entirely meet criteria for
delusional disorder
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UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER
PSYCHOTIC DISORDER
DIAGNOSITIC CRITERIA
 This category applies to presentations in which symptoms
characteristic of a schizophrenia spectrum and other
psychotic disorder that cause clinically significant distress or
impairment in social, occupational, or other important areas
of functioning predominate but do not meet the full criteria
for any of the disorders in the schizophrenia spectrum and
other psychotic disorders diagnostic class.
 This is used in situations in which the clinician chooses not
to specify the reason that the criteria are not met for a
specific schizophrenia spectrum and other psychotic
disorder, and includes presentations in which there is
insufficient information to make a more specific diagnosis
(e.g., in emergency room settings).
DELUSIONAL DISORDER
DIAGNOSITIC CRITERIA
A. The presence of one (or more) delusions with a duration of
one month or longer
B. Criterion A for schizophrenia has never been met.
Note: Hallucinations, if present, are not prominent and are
related to the delusional theme (e.g., the sensation of being
infested with insects associated with delusions of infestation).
C. Apart from the impact of the delusion(s) or its
ramifications, functioning is not markedly impaired, and
behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred,
these have been brief relative to the duration of the
delusional periods.
E. The disturbance is not attributable to the physiological
effects of a substance or another medical condition and is
not better explained by another mental disorder, such as
body dysmorphic disorder or obsessive-compulsive
disorder
Specify whether:
 Erotomanic type:
o This subtype applies when the central theme of
the delusion is that another person is in love with
the individual.
 Grandiose type:
o This subtype applies when the central theme of
the delusion is the conviction of having some
great (but unrecognized) talent or insight or
having made some important discovery.
 Jealous type:
o This subtype applies when the central theme of
the individual’s delusion is that his or her spouse
or lover is unfaithful.
 Persecutory type:
o This subtype applies when the central theme of
the delusion involves the individual’s belief that
he or she is being conspired against, cheated,
spied on, followed, poisoned or drugged,
maliciously maligned, harassed, or obstructed in
the pursuit of long-term goals.
 Somatic type:
o This subtype applies when the central theme of
the delusion involves bodily functions or
sensations.
 Mixed type:
o This subtype applies when no one delusional
theme predominates.
 Unspecified type:
o This subtype applies when the dominant
delusional belief cannot be clearly determined or
is not described in the specific types (e.g.,
referential delusions without a prominent
persecutory or grandiose component).
Specify if:
 With bizarre content:
o Delusions are deemed bizarre if they are clearly
implausible, not understandable, and not derived
from ordinary life experiences (e.g., an
individual’s belief that a stranger has removed his
or her internal organs and replaced them with
someone else’s organs without leaving any
wounds or scars)
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Specify if:
The following course specifiers are only to be used after a 1 -
year duration of the disorder:
 First episode, currently in acute episode
o First manifestation of the disorder meeting the
defining diagnostic symptom and time criteria.
o An acute episode is a time period in which the
symptom criteria are fulfilled.
 First episode, currently in partial remission
o Partial remission is a time period during which an
improvement after a previous episode is maintained
and in which the defining criteria of the disorder are
only partially fulfilled.
 First episode, currently in full remission
o Full remission is a period of time after a previous
episode during which no disorder-specific symptoms
are present.
 Multiple episodes, currently in acute episode
 Multiple episodes, currently in partial remission
 Multiple episodes, currently in full remission
 Continuous
o Symptoms fulfilling the diagnostic symptom criteria of
the disorder are remaining for the majority of the
illness course, with subthreshold symptom periods
being very brief relative to the overall course.
 Unspecified
Specify current severity:
 Severity is rated by a quantitative assessment of the
primary symptoms of psychosis, including delusions,
hallucinations, disorganized speech, abnormal
psychomotor behavior, and negative symptoms. Each of
these symptoms may be rated for its current severity
(most severe in the last 7 days) on a 5-point scale ranging
from 0 (not present) to 4 (present and severe). (See
Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of delusional disorder can be made without
using this severity specifier.
ASSOCIATED FEATURES SUPPORTING DIAGNOSIS
 Social, marital, or work problems can result from the delusional
beliefs of delusional disorder.
 Individuals with delusional disorder may be able to factually
describe that others view their beliefs as irrational but are unable to
accept this themselves (i.e., there may be "factual insight" but no
true insight).
 Many individuals develop irritable or dysphoric mood, which can
usually be understood as a reaction to their delusional beliefs.
 Anger and violent behavior can occur with persecutory, jealous,
and erotomanic types. The individual may engage in litigious or
antagonistic behavior (e.g., sending hundreds of letters of protest to
the government).
 Legal difficulties can occur, particularly in jealous and erotomanic
types.
EPIDEMIOLOGY
 Moreover, delusional disorder may be underreported
because delusional patients rarely seek psychiatric help
unless forced to do so by their families or by the courts.
 Although uncommon, has a relatively steady rate
 The prevalence of delusional disorder in the United States
is currently estimated to be 0.2 to 0.3%.
 Thus, delusional disorder is much rarer than
schizophrenia, which has a prevalence of about 1%, and
the mood disorders, which have a prevalence of about
5%.
 The annual incidence of delusional disorder is one to
three new cases per 100,000 persons.
 The mean age of onset is about 40 years, but the range
for age of onset runs from 18 years of age to the 90s.
 A slight preponderance of female patients exists.
o Men are more likely to develop paranoid delusions
o Women are more likely to develop delusions of
erotomania.
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 Many patients are married and employed, but some
association is seen with recent immigration and low
socioeconomic status.
ETIOLOGY
 The cause of delusional disorder is unknown.
 Patients currently classified as having delusional disorder
probably have a heterogeneous group of conditions with
delusions as the predominant symptom.
 Data come from family studies report an increased
prevalence of delusional disorder and related personality
traits (e.g., suspiciousness, jealousy, and secretiveness)
in the relatives of delusional disorder probands.
 Long-term follow-up of patients with delusional disorder
indicates that the diagnosis of delusional disorder is
relatively stable, with few patients being reclassified
BIOLOGICAL FACTORS
 A wide range of nonpsychiatric medical conditions and
substances, including clear-cut biological factors, can
cause delusions
 Unique, and not yet understood, factors in a patient’s brain
and personality are likely to be relevant to the specific
pathophysiology of delusional disorder.
 The neurological conditions most commonly associated
with delusions affect the limbic system and the basal
ganglia.
o Patients whose delusions are caused by neurological
diseases and who show no intellectual impairment
tend to have complex delusions similar to those in
patients with delusional disorder.
o Patients with neurological disorder with intellectual
impairments often have simple delusions unlike those
in patients with delusional disorder.
 Delusional disorder can arise as a normal response to
abnormal experiences in the environment, the
peripheral nervous system, or the central nervous
system (CNS).
o If patients have erroneous sensory experiences of
being followed (e.g., hearing footsteps), they may
come to believe that they are actually being followed.
o This hypothesis hinges on the presence of
hallucinatory-like experiences that need to be
explained.
PSYCHODYNAMIC FACTORS
FREUD’S CONTRIBUTION
 Sigmund Freud believed that delusions, rather than
being symptoms of the disorder, are part of a healing
process
 Major contribution: was to demonstrate the role of
projection in the formation of delusional thought.
 He described projection as the main defense
mechanism in paranoia.
PARANOID PSEUDOCOMMUNITY
 Norman Cameron described seven situations that
favor the development of delusional disorders:
o an increased expectation of receiving sadistic
treatment,
o situations that increase distrust and suspicion,
o social isolation,
o situations that increase envy and jealousy,
o situations that lower self-esteem,
o situations that cause persons to see their own
defects in others, and
o situations that increase the potential for
rumination over probable meanings and
motivations.
 When frustration from any combination of these
conditions exceeds the tolerable limit, persons
become withdrawn and anxious; they realize that
something is wrong, seek an explanation for the
problem, and crystallize a delusional system as a
solution.
ERIKSONS’ CONCEPT
 Concept of trust versus mistrust in early development
is a useful model to explain the suspiciousness of a
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paranoid individual who never went through the
healthy experience of having his or her needs
satisfied by what Erikson termed the “outer-
providers.”
DEFENSE MECHANISM
 Patients with delusional disorder use primarily:
o Reaction formation. As a defense against
aggression, dependence needs, and feelings of
affection and transform the need for dependence
into staunch independence.
o Denial. To avoid awareness of painful reality
o Projection. use projection to protect themselves
from recognizing unacceptable impulses in
themselves
OTHER FACTORS
 Delusions have been linked to a variety of additional
factors such as social and sensory isolation,
socioeconomic deprivation, and personality
disturbance.
o Deaf and visually impaired individuals and possibly
immigrants with limited ability in a new language may
be more vulnerable to delusion formation than the
normal population.
 Vulnerability is heightened with advanced age.
o Delusional disturbance and other paranoid features
are common in elderly adults.
DEVELOPMENT AND COURSE
 On average, global function is generally better than that observed
in schizophrenia.
 Although the diagnosis is generally stable, a proportion of
individuals go on to develop schizophrenia.
 Although it can occur in younger age groups, the condition may be
more prevalent in older individuals.
CULTURE RELATED DIAGNOSTIC ISSUES
 Cultural and religious background must be taken into account in
evaluating the possible presence of delusional disorder because the
content of delusions also varies across cultural contexts.
FUNCTIONAL CONSEQUENCES
 Functional impairment is usually more circumscribed than that
seen with other psychotic disorders.
 Although in some cases, the impairment may be substantial and
include poor occupational functioning and social isolation.
 A common characteristic of individuals with delusional disorder is
the apparent normality of their behaviour and appearance when
their delusional ideas are not being discussed or acted on.
DIFFERENTIAL DIAGNOSIS
A. Obsessive- compulsive and related disorders
 If an individual with OCD is completely convinced that his or her
OCD beliefs are true, then the diagnosis of obsessive-compulsive
disorder, with absent insight/delusional beliefs specifier, should be
given rather than a diagnosis of delusional disorder.
 Similarly, if an individual with body dysmorphic disorder
(BDD) is completely convinced that his or her BDD beliefs are
true, then the diagnosis of body dysmorphic disorder, with absent
insight/delusional beliefs specifier, should be given rather than a
diagnosis of delusional disorder.
B. Delirium, major neurocognitive disorder, psychotic disorder
due to another medical condition, substance/ medication
induced disorder
 Individuals with these disorders may present with symptoms that
suggest delusional disorder.
 For example, simple persecutory delusions in the context of major
neurocognitive disorder would be diagnosed as major
neurocognitive disorder, with behavioral disturbance.
 A substance/ medication-induced psychotic disorder cross-
sectionally may be identical in symptomatology to delusional
disorder but can be distinguished by the chronological relationship
of substance use to the onset and remission of the delusional
beliefs.
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C. Schizophrenia and schizophreniform disorder
 Delusional disorder can be distinguished from schizophrenia and
schizophreniform disorder by the absence of the other
characteristic symptoms of the active phase of schizophrenia.
D. Depressive and bipolar disorders and schizoafferctive
disorder
 May be distinguished from delusional disorder by the temporal
relationship between mood disturbance & delusions & by the
severity of the mood symptoms.
 If delusions occur exclusively during mood episodes, the
diagnosis is depressive or bipolar disorder with psychotic features.
 Mood symptoms that meet full criteria for a mood episode can be
superimposed on delusional disorder.
 Delusional disorder can be diagnosed only if the total duration of
all mood episodes remains brief relative to the total duration of the
delusional disturbance.
CULTURE BOUND SYNDROMES
 Specific arrays of behavioral and experiential phenomena
that tend to present themselves preferentially in particular
sociocultural contexts and are readily recognized as
illness behavior by most participants in that culture
 Treatment: therapies, collaboration with indigenous healer
 The clinician is advised to:
o Know the demographics
o Recognize the existence of a local pattern
EXAMPLE
1. Amok:
o dissociative episode characterized by a period of
brooding followed by an outburst of violent, aggressive,
or homicidal behavior directed at persons and objects.
o Precipitated by slight insult
2. Ataque de nervios:
o dissociative experiences, seizurelike or fainting
episodes, and suicidal gestures are prominent in some
attacks but absent in others
o general feature is a sense of being out of control
3. Bilis and colera ( muina):
o due to strongly experienced anger or rage; symptoms
are acute nervous tension, headache, trembling,
screaming, stomach disturbances, and severe cases,
loss of consciousness
4. Bouffe delirante:
o a sudden outburst of agitated and aggressive behavior,
marked confusion, and psychomotor excitement; may
sometimes be accompanied by visual and auditory
hallucinations or paranoid ideation
5. Brain fag:
o a condition experienced by high school or university
students in response to the challenges of schooling;
symptoms include difficulties in concentrating,
remembering, and thinking
6. Dhat
o severe anxiety and hypochondriacal concerns
associated with the discharge of semen, whitish
discoloration of the urine, and feelings of weakness and
exhaustion
7. Falling-out or blackout:
o sudden collapse, which sometimes occurs without
warming but is sometimes preceded by feelings of
dizziness or swimming in the head; the person's eyes
are usually open, but the person claims an inability to
see
8. Ghost sickness:
o a preoccupation with death and the deceased
(sometimes associated with witchcraft)
9. Hwa-byung (also known as wool-hwa-byung):
o attributed to the suppression of anger; symptoms include
insomnia, fatigue, panic, fear of impending death,
dysphoric affect, indigestion, anorexia, dyspnea,
palpitations, generalized aches and pains, and a feeling
of a mass in the epigastrium
10. Koro:
o episode of sudden and intense anxiety that the penis (or,
in women, the vulva and nipples) will recede into the
ARBOLEDA, Leigh | PAMPLONA, Hosanne | SENA, Gab | WONG, Anjeh
1.1
body and possibly cause death
11. Latah:
o hypersensitivity to sudden fright, often with echopraxia,
echolalia, command obedience, and dissociative or
trancelike behavior; more frequent in middle-aged
women
12. Locura:
o severe form of chronic psychosis; attributed to an
inherited vulnerability, to the effect of multiple life
difficulties, or to a combination of both factors
13. Mal de ojo:
o fitful sleep, crying without apparent cause, diarrhea,
vomiting and fever in a child or infant
14. Nervios:
o refers both to a general state of vulnerability to stressful
life experiences and to a syndrome brought on by
difficult life circumstances; includes a wide range of
symptoms of emotional distress, somatic disturbance,
and inability to function
15. Piblokto:
o abrupt dissociative episode with extreme excitement of
up to 30 min. and frequently followed by convulsive
seizures and coma lasting up to 12 hrs
o person may be withdrawn or mildly irritable for hours or
days before the attack and typically reports complete
amnesia for the attack
o during the attack they may tear off their clothes, break
furniture, shout obscenities, eat feces, flee from
protective shelters, or perform other irrational or
dangerous acts
16. Qi-gong psychotic reactions:
o acute, time-limited episodes of dissociative, paranoid, or
other psychotic or nonpsychotic symptoms that may
occur after participation in the Chinese folk health-
enhancing practice of qi-gong (exercise of vital energy)
17. Rootwork (mal puesto or brujeria):
o set of cultural interpretations that ascribe illness to
hexing, witchcraft, sorcery, or evil influence of another
person; symptoms are generalized anxiety and
gastrointestinal complaints, weakness, dizziness, fear of
being poisoned, and sometimes fear of being killed
(voodoo death)
18. Sangue dormido (sleeping blood):
o pain, numbness, tremor, paralysis, convulsions, stroke,
blindness, heart attack, infection, and miscarriages
19. Shenjing shuariuo (neurasthenia):
o characterized by physical and mental fatigue, dizziness,
headaches, other pains, concentration difficulties, sleep
disturbance, and memory loss; may include GI
problems, sexual dysfunction, irritability, excitability, and
various signs suggesting disturbance of the autonomic
nervous system
20. Shen-k'uei (Taiwan); shenkui (China):
o marked anxiety or panic symptoms with somatic
complaints with no physical cause demonstrated
o symptoms include dizziness, backache, fatigability,
general weakness, insomnia, frequent dreams, and
complaints of sexual dysfunction, such as premature
ejaculation and impotence attributed to excessive semen
loss from frequent intercourse, masturbation, nocturnal
emission, or passing of white turbid urine believed to
contain semen.
21. Shin-byung:
o syndrome with initial phases characterized by anxiety
and somatic complaints (weakness, dizziness, fear, GI
problems), with subsequent dissociation and possession
by ancestral spirits
22. Spell:
o trance state of persons communicating• with deceased
relatives or spirits; maybe associated with brief periods
of personality change
23. Susto (frigh or soul loss):
o illness attributed to a frightening event that causes the
soul to leave the body resulting in unhappiness and
sickness;
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 PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders 1.1

o typical include appetite disturbances, inadequate or Ziprasidone 0/+ + 0

excessive sleep, troubled sleep or dreams, feelings of
sadness, lack of motivation to do anything, and feelings
of low self-worth or dirtiness; somatic symptoms include
muscle aches and pains, headache, stomachache, and
diarrhea
24. Taijin kyofu sho:
o resembling social phobia in DSM; the syndrome refers to
an intense fear that one's body, its parts or its functions,
displease, embarrass, or are offensive to other people in
appearance, odor, facial expressions, or movements
25. Zar:
o the experience of spirits possessing a person; with
dissociative episodes that include shouting, laughing,
hitting the head against a wall, singing, or weeping
o Shows apathy and withdrawal, refusing to eat or carry
out daily tasks or may develop a long-term relationship
with the possessing spirit
TREATMENT OF PSYCHOTIC DISORDERS
 The complexity of schizophrenia renders any single
therapeutic approach inadequate to deal with multifaceted
disorder
 Patients with schizophrenia benefit more from the
combined use of antipsychotic drugs and psychosocial
treatment
Hospitalization
Indicated for the following:
o Diagnostic purposes
o Stabilization of medications
o Patient’s safety because of suicidal or homicidal ideation
o Disorganized or inappropriate behavior
o Inability to take care of basic needs (food, clothing,
shelter)
Establishing an effective association between patients and
community support system
o primary goal of hospitalization
Pharmacotherapy: antipsychotics are the mainstay
o Antipsychotics
1. First generation
 Older conventional
 Dopamine receptor antagonists
 Usually associated with extrapyramidal side effects
a. Haloperidol (Haldol, Serenace) 5-20 mg/day
SE: EPS
b. Chlorpromazine(Thorazine, Psynor, Laractyl)
100-600 mg/day
SE: sedation, hypotension
2. Second generation
 Newer drugs
 Serotonin dopamine antagonists (SDAs)
a. Risperidone (Risperdal) 1-4 mg/day
b. Clozapine (Leponex) 100-200 mg/day: side
effect: agranulocytosis
c. Olanzapine (Zyprexa) 5-10 mg/day
d. Ziprasidone (not found in Philippines)
e. Quetiapine (Seroquel) 200-600 mg/day
f. Amisulpride (Solian) 50-400 mg/day
g. Aripiprazole (Abilify) 5-15 mg/day
o Benzodiazepine
 decrease agitation during acute psychosis
 reduce antipsychotics needed
o Long-term Treatment Concerns
Side Effect
Drug Increased
Weight Extrapyramidal
Plasma
Gain Symptoms
Prolactin
Risperidone ++ ++ +++
Aripiprazole 0/+ + 0
PHARMACOTHERAPY
CHLORPROMAZINE
 May be the most important single contribution to the
treatment of a psychiatric illness
 Henri Laborit noticed that administration of
chlorpromazine before surgery resulted to less anxiety
 Effective in reducing hallucinations, delusions and
excitement
 Side effect: symptoms similar to Parkinsonism
CLOZAPINE (CLOZARIL)
 The first effective antipsychotic with negligible
extrapyramidal side effects
 Associated with risk of agranulocytosis
PHASES OF TREATMENT IN SCHIZOPHRENIA
TREATMENT OF ACUTE PSYCHOSIS
 require immediate attention
 focuses on alleviating the most severe psychotic symptoms
 last from 4-8 weeks
 associated with severe agitation  frightening delusions,
hallucinations, suspiciousness and stimulant abuse
 Antipsychotics and benzodiazepines
o Results in rapid calming of patients
 Intramuscular injection of antipsychotics produces a more
rapid effect
 Antipsychotics administered single IM injection without an
excess sedation:
o Haloperidol (Haldol)^^
o Fluphenazine (Prolixin, Permitil)^^
o Olanzapine (Zyprexia)^
o Ziprasidone (Geodon)^
 ^ =Does not cause extrapyramidal side effects
 ^^=Cause frightening dystonias or akathisia
 low potency antipsychotics are often associated with
sedation and postural hypotension
 delayed treatment may worsen the patient’s prognosis
TREATMENT DURING STABILIZATION AND
MAINTENANCE PHASE
 the illness is in a relative stage of remission with only
minimal psychotic symptoms
 Goal: to prevent psychotic relapse and to assist patients in
improving their level of functioning
 stopping the medication increases the risk 5x
 multiepisode patients receive maintenance treatment for at
least 5 years
NONCOMPLIANCE
 40-50% of patients become noncompliant within 1-2 years
 Compliance increases when long-acting medication is used
instead of oral medication
 Fluphenazine, haloperidol &resperidone
o Long-acting injectables
STRATEGIES FOR POOR RESPONDERS
 a 4-6 week trial on an adequate dose of an antipsychotic 
monitoring the plasma concentration 00> a very low plasma
concentration may indicate that the patient has been
noncompliant or a rapid metabolizer of the drug
 if responding poorly  increase the dose above the usual
therapeutic level or changing to another drug
 if the nonresponsive to DRA change to SDA
 CLOZAPINE
o effective for patients who responded poorly to DRAs
o had the clearest advantage over conventional drugs in
severe psychotic sx

Olanzapine +++ + 0 MANAGING SIDE EFFECTS

 patients frequently experience side effects before they
Quetiapine ++ 0 0 experience clinical improvement
 side effects may begin immediately

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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders 1.1

Low-potency drugs SOCIAL THERAPY

o SE: sedation , postural hypotension, anticholinergic  Sometimes referred to as behavioral skills therapy
effects  Along with pharmacological therapy, this therapy can be
High-potency drugs
directly supportive and useful to the patient.
o SE: extrapyramidal side effects
 Behavioral skills training addresses behaviors through the
use of videotapes of others and of the patient, role playing in
EXTRAPYRAMIDAL SIDE EFFECTS therapy, and homework assignments for the specific skills
 Alternatives for treatment: being practiced.
o reduction of the dose  Social skills training has been shown to reduce relapse rates
o adding an anti-Parkinson medication as measured by the need for hospitalization.
o changing the patient to an SDA Goals and Targeted Behaviors for Social Skills
 Anticholinergic anti-Parkinson medication Therapy
o most effective anti-Parkinson drug TARGETED
PHASE GOALS
o SE: dry mouth, constipation, blurred vision, memory loss BEHAVIORS
 I blockers
2
 Establish  Empathy and
o (propranolol) effective for treating akathisia therapeutic rapport
Most patients respond to dosages between 30-90 mg/day alliance  Verbal and
 Assess social nonverbal
Stabilization
performance and communication
TARDIVE DYSKINESIA and
perception skills
 20-30% on long term treatment with conventional DRA  assessment
 Assess behaviors
tardive dyskinesia that provoke
 Individuals who are more vulnerable to developing tardive expressed
dyskinesia emotion
 Onset of abnormal movements usually occurs either while  Express positive  Compliments,
the patient is receiving an antipsychotic or within 4 weeks of feelings within appreciation,
discontinuing an oral antipsychotic or 8 weeks after the family interest in
Social
withdrawal of a depot antipsychotic  Teach effective others
performance
strategies for  Avoidance
within family
coping with response to
 Recommendations for preventing and managing tardive
conflict criticism, stating
dyskinesia: preferences and
o using the lowest effective dose refusals
o prescribing cautiously with children, elderly patients and  Correctly identify  Reading a
patients with mood disorders Social content, context, message
o examining patients on a regular basis for evidence of perception in and meaning of  Labeling an idea
tardive dyskinesia the family messages Summarizing
o considering alternatives to the antipsychotic being used other's intent
and considering dosage reduction when tardive  Enhance  Conversational
dyskinesia worsens socialization skills
skills  Dating
Extrafamilial
Clozapine  Enhance Recreational
relationships
o Has been shown to be effective in reducing severe prevocational activities Job
tardive dyskinesia or tardive dystonia and vocational interviewing,
skills work habits
OTHER SIDE EFFECTS Maintenance  Generalize skills to new situations
 Sedation and postural hypotension
o Important side effects for patients who are being treated FAMILY ORIENTED THERAPY
with low-potency DRAs  Focus: on the immediate situation and should include
o Effects are often most severe during the initial dosing identifying and avoiding potentially troublesome situations
with these medications  When problems do emerge with the patient in the family, the
 Galactorrhea and irregular menses – all DRAs and some aim of the therapy should be to resolve the problem quickly
SDAs  Family should be advised not to ask pt to resume regular
 Osteoporosis activties too quickly
 Therapists must help both the family and the pt understand
OTHER BIOLOGICAL THERAPIES & learn about schizophrenia
ELECTROCONVULSIVE THERAPY  Must encourage discussion of the psychotic episode and the
 Has been studied in both acute and chronic schizophrenia events leading up to it
 Antipsychotic meds should be administered during & after  Ignoring the psychotic episode, a common occurrence, often
ECT increases the shame associated w/ the event & does not
 Studies in recent-onset patients: ECT is as effective as exploit the freshness of the episode to understand it better
antipsychotic meds and more effective than psychotherapy  Talking openly w/ the psychiatrist and w/ the relative w/
 Other studies: Supplementing antipsychotic meds w/ ETC > schizophrenia often eases fears of all parties
antipsychotic meds alone  Directs family therapy toward long-range application of
stress-reducing & coping strategies & toward the patient's
gradual reintegration into everyday life
PSYCHOSURGERY
 Must control the emotional intensity of family sessions w/ pt.
 No longer considered an appropriate treatment
 Excessive expression of emotion during a session can
 Practiced on a limited experimental basis for severe, damage a pt's recovery process and undermine potentially
intractable cases. successful future family therapy.
 Especially effective in reducing relapses.
PSYCHOSOCIAL THERAPY
 Include a variety of methods to  social abilities, self- SCHIZOPHRENIA
sufficiency, practical skills, & interpersonal communication in
CASE MANAGEMENT
schizophrenia patients
 Goal: to enable persons who are severely ill to develop  The success of the management program depends on the
social and vocational skills for independent living educational background, training, and competence of the
 Carried out at many sites: hospitals, outpatient clinics, individual case manager
mental health centers, day hospitals, and home or social  The case manager ensures that their efforts are coordinated
clubs and that the patient keeps appointments and complies w/
treatment plans;
 Manager may make home visits and may even accompany

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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders
patient to work.
 However,they often have too many cases to manage
effectively
 Ultimate benefits are yet to be discovered
ASSERTIVE COMMUNITY TREATMENT (ACT)
 Was originally developed for the delivery of services for
persons w/ chronic mental illnesses, w/ each patient being
assigned to a multidisciplinary team, ready to render
services to patient 24/7
 ACT is mobile & an intensive intervention that provides Tx,
rehab, & support activities (including home delivery of
medications, monitoring of mental and physical health, etc)
 Team has a fixed caseload of patients & delivers all services
when and where needed by the patient, 24 hours a day, 7
days a week
 There is a high staff-to-patient ratio (1:12)
 ACT ↓ risk of rehospitalisation for persons with schizo, but
they are labor-extensive and expensive programs to
administer.
GROUP THERAPY
 Generally focuses on real-life plans, problems, and
relationships.
 Some investigators doubt that dynamic interpretation and
insight therapy are valuable for typical patients w/
schizophrenia
 Effective in reducing social isolation, increasing the sense of
cohesiveness, and improving reality testing for patients with
schizo.
 Groups may be behaviorally oriented, psychodynamically or
insight oriented, or supportive
 Groups led in a supportive manner appear to be most
helpful for schizophrenia patients.
COGNITIVE BEHAVIORAL THERAPY
 Used to improve cognitive distortions, reduce distractibility,
and correct errors in judgment.
 Reports of being able to ameliorate delusions and
hallucinations.
 Patients who might benefit generally have some insight into
their illness
INDIVIDUAL PSYCHOTHERAPY
 Developing a therapeutic relationship that the patient
experiences as safe is critical.
 Schizo patients who are able to form a good therapeutic
alliance are likely to remain in psychotherapy, to remain
compliant with medications, & to have good outcomes at 2-
year follow-up evaluations.
 Psychotherapy for a schizophrenia patient should be
thought of in terms of decades, rather than sessions,
months, or even years.
 Therapists should scrupulously respect a pt's distance and
privacy,
 Should demonstrate simple directness, patience, sincerity,
and sensitivity to social conventions in preference to
premature informality & the condescending use of first
names
 Pt is likely to perceive exaggerated warmth or professions of
friendship as attempts at bribery, manipulation, or
exploitation.
 Flexibility is essential in establishing a working alliance with
the patient. (may have meals w/ the patient, sit on the floor,
go for a walk, eat at a restaurant, accept a&give gifts, play
table tennis, remember the patient's birthday, or just sit
silently with the patient)
 Major aim is to convey the idea that the therapist is
trustworthy, wants to understand the patient and tries to do
so, and has faith in the patient's potential as a human, no
matter how disturbed, hostile, or bizarre the patient may be
at the moment
PERSONAL PSYCHOTHERAPY
 Recently developed flexible type of individual Tx for schizo
patients
 Objective is to enhance personal & social adjustment & to
forestall relapse
ARBOLEDA, Leigh | PAMPLONA, Hosanne | SENA, Gab | WONG, Anjeh
1.1
 A select method using social skills & relaxation exercises,
psychoeducation, self-reflection, self-awareness, &
exploration of individual vulnerability to stress.
 Provides a setting that stresses acceptance and empathy.
 Pts receiving personal therapy show improvement in social
adjustment (includes work performance, leisure, &
interpersonal relationships) and have a lower relapse rate
after 3 yrs than patients not receiving personal therapy.
DIALECTICAL BEHAVIORAL THERAPY
 Combines cognitive and behavioral theories in both
individual and group settings
 Proved useful in borderline states and may have benefit in
schizophrenia
 Emphasis is placed on improving interpersonal skills in the
presence of an active and empathic therapist
VOCATIONAL THERAPY
 Variety of methods and settings are used to help patients
regain old skills or develop new ones.
 Include sheltered workshops, job clubs & part-time or
transitional employment programs.
 Enabling patients to become gainfully employed is both a
means toward, and a sign of, recovery
 Many schizophrenia patients are capable of performing
high-quality work despite their illness
 Others may exhibit exceptional skill or even brilliance in a
limited field as a result of some idiosyncratic aspect of their
disorder
ART THERAPY
 Many schiz patients benefit from art therapy
 Provides them w/ an outlet for their constant bombardment
of imagery
 Helps them communicate w/ others & share their inner,
often frightening world with others.
 In some circles, the art of the mentally ill is highly
collectable; however, whether purchased or not, the
production of a work that is appreciated by others can do
much to raise self-esteem
INTEGRATING PSYCHOSOCIAL AND MEDICATION
TREATMENTS
 Antipsychotic medication has been established as the single
most effective treatment for schizophrenia, but it is not
sufficient for many patients who greatly benefit from the
addition of psychosocial therapy.
 Many studies show that combining both approaches
produces the best results
***END***
Schizophrenia Misconception:
 People With Schizophrenia Have a Split
Personality
 All People With Schizophrenia Are Violent
 Schizophrenia Is Easy to Recognize Because
People Act "Crazy"
 Schizophrenia Runs in Families
 People With Schizophrenia Get Worse Over Time
 People With Schizophrenia Can Never Recover
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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders 1.1 1.1a
Schizophrenia-Spectrum and Other Psychotic Disorders
June 18, 2015
Dr. Jose Gerardo Los Baños
………………….APPENDIX……………………..

FIRST GENERATION ANTIPSYCHOTICS

DRUG/BRAND MOA INDICATIONS ADR OTHER NOTES
/DOSE
HALOPERIDOL  Phenylbutylpiperadin  Schizophrenia,  Neuroleptic malignant syndrome  Severe
Haldol, e; antagonizes psychosis,  worsethanEPS;highHR,temp,BP-- neurotoxicity
dopamine D1 and D2 sedation >rhabdomyolysis manifesting as
Serenace
receptors in brain  Tourette disorder  young males at higher risks rigidity or inability
 depresses reticular  Acute agitation  Agranulocytosis to walk or talk may
activating system  Depression, drowsiness, occur in patients
and inhibits release anorexia, anxiety with thyrotoxicosis
5-20 mg/day of hypothalamic and  Paralytic ileus also receiving
hypophyseal  Priapism antipsychotics
hormones  Prolonged QT interval
 Seizure
 Sudden cardiac death
 Torsades de pointes

CHLORPRO-  Phenothiazine;  Behavioural  Tardive dyskinesia (on long-term  Anticholinergic

MAZINE antagonizes disorders, therapy) anti-parkinsonian
Thorazine, dopamine D2  Nausea and  Involuntary movements of agent may be
receptors in brain; vomiting extremities may also occur needed to counter
Psynor, Laractyl depresses release of  Preoperative  Dry mouth, constipation, urinary EPS
hypothalamic and apprehension retention, mydriasis, agitation,  Potential for
hypophyseal insomnia, depression and priapism
hormones; may also convulsions
100-600 depress reticular  Postural
activating system hypotension,ECGchanges
mg/day  Allergic skin reaction,
amenorrhoea, gynecomastia,
weight gain
 Hyperglycaemia and raised
serum cholesterol
 Agranulocytosis
 Instantaneous deaths associated
with ventricular
tachyarrhythmias
 Marked elevation of body
temperature with heat stroke
 Neuroleptic malignant syndrome,
extrapyramidal dysfunction

SECOND GENERATION ANTIPSYCHOTICS

DRUG/BRAND/ MOA INDICATIONS ADR OTHER
DOSE NOTES
RISPERIDONE  An  Schizophrenia  Weight gain, anxiety, nausea and vomiting,  mortality in
Risperdal benzisoxazole (both adults and rhinitis, erectile dysfunction, organismic elderly
1-4 mg/day and an adolescent) dysfunction, edema, blurred vision, patients
antagonist of  Bipolar Mania constipation, dyspepsia, and increased with
the serotonin 5- (Children, pigmentation Dementia
HT2A, dopamine adolescents and  Galactorrhoea, gynecomastia, menstrual related
D2-α1- and α2- adults) disorder Psychosis
adrenergic, and  Irritability in  extrapyramidal symptoms, dizziness,
histamine H1 Autistic Disorder hyperkinesias, somnolence, and nausea
receptors (most common drug-related reason for
discontinuation of risperidone)
 Potentially Fatal: Neuroleptic malignant
syndrome may occur rarely; seizures.
CLOZAPINE  A  Treatment  Commonly, sedation, dizziness, nausea and  mortality in
Leponex dibenzodiazepin Resistant vomiting. elderly
100-200 mg/day e. Schizophrenia  Drowsiness, headache; constipation; patients
 It is an  Reduction in the anxiety, confusion, fatigue, transient fever. with
antagonist of 5- Risk of Recurrent  Rarely, dysphagia, acute pancreatitis, Dementia
HT2A, D1, D3, Suicidal Behavior cholestatic jaundice; orthostatic related
D4 and α in Schizophrenia hypotension, tachycardia; seizures; Psychosis,
receptors or Schizoaffective hypersalivation. Increased
Disorders  Potentially Fatal: Rarely, risk of
thromboembolism. Reversible neutropenia agranulo-
which may progress to a potentially fatal cytosis,
agranulocytosis (especially to Caucasians seizure and
and Scandinavians [prone to myocarditis
agaranulocytosis) - need for CBC
monitoring). Fatal myocarditis.
OLANZAPINE  In addition to 5-  Schizophrenia  Postural hypotension; constipation;  mortality in
Zyprexa HT2A and D2  Bipolar I disorder dizziness; weight gain; agitation; elderly
antagonism, (Manic or Mixed insomnia; akathisia; tremor; personality patients
olanzapine is an Episode) disorders; oedema; somnolence; with
5-10 mg/day

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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders 1.1

antagonist of increased appetite Dementia

the D1, D4, 5-  Antimuscarinic effects; speech difficulty; related
HT1A, exacerbation of Parkinson's disease; Psychosis
muscarinic M1 hallucinations; asthenia
through M5, and  ábody temperature; bradycardia;
H1 receptors. hyperprolactinaemia; QT prolongation
(uncommon); asymptomatic elevations of
hepatic transaminases
 Potentially Fatal: Exacerbation of pre-
existing diabetes sometimes leading to
ketoacidosis. Neuroleptic malignant
syndrome.
THIRD GENERATION ANTIPSYCHOTICS

DRUG/BRAND/ MOA INDICATIONS ADR OTHER

NOTES
DOSE

QUETIAPINE  In addition to  safe, almost no side effect according to  ámortality in

Seroquel being an  Schizophrenia and Dr. Los Baños elderly
antagonist of D2 Bipolar I disorder  Headache, asthenia, abdominal pain, back patients with
and 5-HT2, also pain, fever, chest pain, postural and Dementia
200-600 mg/day blocks 5-HT6, Dl orthostatic hypotension, hypertension, related
and HI, and constipation, dry mouth, dyspepsia, Psychosis;
a1 and diarrhoea, leukopenia, elevations in serum suicidal
a2 receptors. It transaminase level, weight gain, myalgia, thoughts and
does not block sedation, dizziness, anxiety, rhinitis, rash, behavior
muscarinic or dry skin, ear pain, UTI, syncope,
benzodiazepine neuroleptic malignant syndrome, variations
receptors. in WBC count, neutropenia, eosinophilia,
elevations in non-fasting serum triglyceride
level and total cholesterol, decrease in
thyroid hormone levels, prolongation of
the QT interval
ARIPIPRAZOLE  A potent 5-HT2A  Acute Mania:  Common: headache,  ámortality in
5-15 mg/day antagonist and is Useful for the somnolence,dyspepsia, anxiety, nausea elderly
indicated for the initial control of  Not a frequent cause of extrapyramidal side patients with
treatment of agitation during a effects Dementia
both manic episode.  Cause akathisia-like activation. related
schizophrenia  Other Uses: Used  Described as restlessness or agitation Psychosis;
and acute mania. successfully as an  It can be highly distressing and often leads suicidal
 A partial D2 add-on to SSRIs to discontinuation of medication. thoughts and
agonist, in treatment-  Insomnia, DM, seizure, galactorrhea, behavior
producing a resistant patients amenorrhea, insomnia, gynecomastia,
functional with mood or breast tension, impotence, frigidity, wt
reduction of anxiety disorders. gain, EPS, GI disorders.
dopamine  Elevation of serum protein levels,
activity constipation, nausea, vomiting, dry mouth.
(Similar AR’s to Risperidone)

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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders 1.1

AMISULPRIDE  Potent 5-HT2A  indicated for the  Similar AR’s to Risperidone, akathisia
5-15 mg/day antagonist and a treatment of  Nervous system disorders:
substituted acute and ▪ Very common: Extrapyramidal symptoms may occur
benzamide chronic ▪ Common: Acute dystonia (spasm torticollis, oculogyric
derivative schizophrenic crisis, and trismus) and Somnolence may appear
 Partial D2 disorder  Reversible without discontinuation of amisulpride upon
agonists compete ▪ For acute treatment with an antiparkinsonian agent
at D2 receptors psychotic
for endogenous ▪ Uncommon: Tardive dyskinesia usually after long term
episodes
dopamine, administration and seizures
▪ For patients with  Antiparkinsonian medication is ineffective or may induce
thereby mixed positive
producing a aggravation of the symptoms
and negative
functional  Psychiatric disorders:
symptoms
reduction of ▪ Common: Insomnia, anxiety, agitation, orgasmic
▪ For patients
dopamine dysfunction
characterised by
activity predominant  Gastrointestinal disorders:
negative ▪ Common: Constipation, nausea, vomiting, dry mouth
symptoms  Endocrine disorders:
▪ Common: increase in plasma prolactin levels which is
reversible after drug discontinuation
 This may result in galactorrhea, amenorrhoea,
gynaecomastia, breast pain, and erectile dysfunction
 Metabolism and nutrition disorders:
▪ Uncommon: Hyperglycemia
 Cardiovascular disorders
▪ Common: Hypotension
▪ Uncommon: Bradycardia
 Cardiac disorders:
▪ Frequency not known: QT interval prolongation and
ventricular arrhythmias such as torsade de pointes,
ventricular tachycardia, which may result in ventricular
fibrillation or cardiac arrest, sudden death.
 Vascular disorders:
▪ Frequency not known: Cases of venous thromboembolism,
including cases of pulmonary embolism and cases of deep
vein thrombosis
 Skin and subcutaneous tissue disorders:
▪ Frequency not known: Angioedema, urticarial

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PSYCHIATRY: Schizophrenia Spectrum and Other Psychotic Disorders 1.1 1.1a
Schizophrenia-Spectrum and Other Psychotic Disorders
June 18, 2015
Dr. Jose Gerardo Los Baños

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