Other psychotic

disorders
TBL 3

Group 4 21/22
Define Psychosis
❖ Describe conditions that affect the mind involving a loss of contact with reality.
❖ Disruptions to a person’s thoughts and perceptions
❖ Individual may have difficulty in distinguishing what is real and what isn’t.
❖ Disruptions are often experienced as seeing, hearing and believing things that aren’t real
❖ Having strange, persistent thoughts, behaviors and emotions.
Delusional
disorder
 Delusional Disorder
● Definition
● Aetiology
● Epidemiology
● Pathophysiology
 Definition
❖ Primary or sole manifestation is a non-bizarre delusion that is fixed and unshakable.
❖ False fixed beliefs not in keeping with the culture.
❖ Great variety of false beliefs that can be held by so many people.
❖ Non-bizarre delusions of at least 1 month's duration not attributed to other
psychiatric disorders.
❖ Delusions about situations in real life: being followed, infected, loved at a distance.
❖ Not real but nonetheless possible.
❖ Several types of delusions may be present and the predominant type is specified.
 Aetiology
1. Genetic
❖ Slight increase of delusional thinking (suspiciousness) in families of delusional disorder

2. Biological

❖ Neurological lesions associated with the temporal lobe, limbic system, and basal ganglia
❖ Response to stimuli in peripheral nervous system (paresthesia perceived as rays from outer
space)

3. Psychosocial

❖ History of physical or emotional abuse, cruel, erratic, unreliable parenting, overly demanding
or perfectionist upbringing
❖ Lack of basic trust: child believes environment is consistently hostile and dangerous
❖ History of deafness, blindness, social isolation and loneliness, recent immigration or abrupt
environmental changes.
 Epidemiology
● 1-2% of all admissions to inpatient mental health facilities
● Mean age of onset: 40 years old with range 18 - 90 years
● Preponderance of female patients
● Widowhood, celibacy, history of substance abuse
● Men: paranoid delusions
● Women: erotomania delusions
 Pathophysiology
❖ No known pathophysiology
❖ Discrete anatomic defects of the limbic system or basal ganglia.
❖ Prominent cortical damage: simple, poorly formed, persecutory delusions.
❖ Lesions of the basal ganglia: less cognitive disturbance & more complex delusional content.
❖ Excessive dopaminergic and reduced acetylcholinergic activity

Basal ganglia disorder Parkinson’s disease, Huntington disease

Deficiency states B12, folate, thiamine

Dementia Alzheimer’s disease, Pick’s disease

Drug induced Cocaine, hallucinogen

 Diagnostic Criteria
Presence of 1 or more delusions that persist for at least 1 month that CANNOT be attributed to other psychiatric disorders

Diagnostic Name Delusional Disorder

Duration ≥1 month

Symptoms * Delusions (Examples in symptom specifier)

Required number of symptoms ≥1

Psychosocial consequences of No marked functional impairment, but social,

symptoms marital, or work problems can result from the
delusional beliefs of delusional disorder.

Exclusions (not better explained by): Schizophrenia

Another medical condition
Substance use
Another mental illness
Symptom ● Erotomanic type
● Grandiose type
Specifier ● Jealous type
● Persecutory type
● Somatic type
● Mixed type
● Unspecified type
● With bizarre content: if not related to reality or a life
experience or not possible, include this specifier

Course ● First episode, currently in acute episode

● First episode, currently in partial remission: currently less
Specifier symptoms than needed for diagnosis
● First episode, currently in full remission: 0 symptoms
● Multiple episodes, currently in acute episode: ≥2 episodes
● Multiple episodes, currently in partial remission
● Multiple episodes, currently in full remission
● Continuous
● Unspecified
 Symptom Specifier
Erotomanic type When another person is in love with the individual

Grandiose type Conviction of having some great (but unrecognized) talent or insight or
having made some important discovery

Jealous type His or her spouse or lover is unfaithful

Persecutory Individual’s belief that he or she is being conspired against, cheated, spied
type on, followed, poisoned or drugged, maliciously maligned, harassed, or
obstructed in the pursuit of long-term goals.

Somatic type involves bodily functions or sensations

Mixed type This subtype applies when no one delusional theme predominates

Unspecified When the dominant delusional belief cannot be clearly determined or is not
type described in the specific types (e.g., referential delusions without a prominent
persecutory or grandiose component)
 ● Many patients with the disorder can function well in society and
Management never come to psychiatric attention.
● Psychiatrists may only meet them when they are evaluating them
for another disorder.
Management is difficult considering the LACK OF INSIGHT.
● Good doctor-patient relationship = Treatment success. Treatment
includes psychotherapy by establishing trust and building a
therapeutic alliance.
An antipsychotic should be started for a trial period of six weeks after
which there is an evaluation of the effectiveness of the medication. Start
a low dose and titrate up as needed.
* Treatment response is better when combining psychotherapy with psychopharmacology.
 Brief
psychotic
disorder
 Brief Psychotic Disorder
According to DSM-5, Brief Psychotic Disorder (BPD) is the sudden onset of
psychotic behaviour that lasts less than 1 month followed by complete
remission with future possible relapses.

It is acute but transient disorder and needs to have presence of one or more of
the following symptoms. At least one of these must be (1), (2), or (3):

1) Delusions
2) Hallucinations
3) Disorganized speech
4) Grossly disorganized or catatonic behaviour
Relevant history
1. Presence of at least one
positive psychotic symptom
2. Duration
3. Investigating if the behaviour
is explained by other causes
● Delusions
● Hallucinations
● Disorganized speech
● Disorganized or catatonic
behaviour
● Have not been less than one
day or more than one month
● Other mood disorders
● Medical condition
● Substance abuse
Epidemiology:

● Increased frequency in populations under high stress such as immigrants, refugees and
earthquake victims

● Higher incidence of brief psychotic disorder in developed countries

● More common in women and in those with personality disorder

Etiology:

The specified trigger of BPD, if present, must be specified as follows:

● With marked stressors (brief reactive psychosis): occur in response to a traumatic event that
would be stressful for anyone in similar circumstances in the same culture

● Without marked stressors: occur in the absence of a traumatic event that would be stressful for
anyone in similar circumstances in the same culture

● With peripartum onset: During pregnancy or four weeks postpartum

● With catatonia
Pathophysiology:

● Not exactly known due to low incidence

● However, there is higher prevalence among patients with personality or
mood disorders
● One or more severe stress factors, such as traumatic events, family
conflict, employment problems, accidents, severe illness, death of a loved
one, and uncertain immigration status, can precipitate brief reactive
psychosis.
Management:

1. Hospitalization
- patients experiencing an acute psychotic attack may have to be hospitalized
briefly so that they can be evaluated and their safety ensured.
1. Pharmacotherapy
- Second generation antipsychotics are considered first-line agents due to its low
adverse effects. Example: Olanzapine, Quetiapine, Ziprasidone
- First generation: Haloperidol, Thiothixene, Chlorpromazine
- Benzodiazepines: may prove helpful to ameliorate symptom manifestation in
acutely combative or agitated individuals.
1. Psychotherapy
- Medically informing the patient and his/her family about the condition and
treatment modalities employed for the particular patient.
Schizophren
iform
disorder
 Schizophreniform Disorder
Symptoms are identical to those of schizophrenia for at least 1 month and return to the patient’s
baseline state within 6 months

Epidemiology:

- Most common in male, adolescent and young adults and is less than half as common as
schizophrenia.
- A lifetime prevalence rate of 0.2% and a 1-year prevalence rate of 0.1% have been
reported.

Aetiology: Causes of schizophreniform disorder is not known.

- Relatives of patients with schizophreniform disorders are at high risk of having other
psychiatric disorder.
Diagnostic Criteria 295.40(F20.81)
Diagnostic Name Schizophreniform

Duration ≥ 1mo, but < 6mo

Symptoms - Delusions
- Hallucinations
- Disorganization of speech
- Disorganization of behavior /catatonia
- Negative Symptoms

Required number of ≥ 2, including at least 1 of the first 3 listed.

symptoms

Exclusions Substances, Other medical conditions, Other psychiatric conditions (schizoaffective disorder and
depressive or bipolar disorder with psychotic features)

Symptoms Specifiers With catatonia

Course Specifiers With good prognostic feature: ≥ 2 of the following:-

- Psychotic symptoms within 4 wk of initial behavioural changes
- Confusion or perplexity
- Good premorbid social and occupational functioning
- No negative symptoms
Without good prognostic feature: ≥ 2 of above features are not present
Course and Prognosis

1. About one-third of individuals with an initial diagnosis of schizophreniform disorder

(provisional) recover within 6-month period and schizophreniform disorder is their final
diagnosis.

2. The majority of the remaining two-thirds of individuals will eventually receive a diagnosis of
schizophrenia or schizoaffective disorder.
Functional Consequences
- For the majority of individuals with schizophreniform disorder who eventually
receive a diagnosis of schizophrenia or schizoaffective disorder, the functional
consequences are similar to the consequences of those disorders.

- Although they may experience functional impairment at time of an episode, they

are unlikely to report a progressive decline in social and occupational functioning.

- Individuals who recover from schizophreniform disorder have better functional

outcomes.
Management
1. Hospitalization

2. Antipsychotic drugs - e.g., risperidone

3. A trial of lithium (Eskalith), carbamazepine (Tegretol), or valproate

(Depakene) may be warranted for treatment and prophylaxis if a patient
has a recurrent episode.

4. Psychotherapy

5. Electroconvulsive therapy - indicated for those with marked catatonic or

depressed features
Schizoaffecti
ve disorder
 Schizoaffective Disorder

❖ Definitions:
➢ It is characterised by same active phase symptoms of both schizophrenia and presence of symptoms of mood
disorder such as manic or depressive symptoms that is not brief relative to the duration of the psychosis.
❖ Epidemiology:
➢ It is a rare occurrence with lifetime prevalence of 0.3%.
➢ It affect higher number in females compared to males.
➢ The depressive type more common in older persons than young adults.
➢ The bipolar type more common in young adults than in older adults
❖ Aetiology:
➢ Exact aetiology is unknown.
➢ Brain chemistry and structure abnormalities.
➢ Genetic.
➢ Medications
 Schizoaffective Disorder
Subtypes of Schizoaffective disorder:

1. The bipolar type, if there is both a manic and depressive cycling.

2. The depressive type, if the disturbance only includes major depressive episodes.

Categories of schizoaffective disorder:

3. Patients with schizophrenia who have mood symptoms

4. Patients with mood disorder who have symptoms of schizophrenia
5. Patients with both mood disorder and schizophrenia
6. Patients with a third psychosis unrelated to schizophrenia and mood disorder
7. Patients whose disorder is on a continuum between schizophrenia and mood disorder
8. Patients with some combination of the above
 DSM-5 Diagnostic Criteria
1. An uninterrupted period of illness during
which there is a major mood episode (major
depressive or manic) concurrent with
Criterion A of schizophrenia.
2. 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.
3. 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.
4. The disturbance is not attributable to the
effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
 Managements of Schizoaffective Disorder
Mainly involves combinations of pharmacotherapy and psychotherapy.

1. Pharmacotherapy :
a. Antipsychotic drugs: paliperidone (FDA approved for schizoaffective disorder),
risperidone and haloperidol to resolve psychosis and aggressive behavior.
b. Mood Stabilizers: Drugs used are lithium, valproic acid and carbamazepine which is to
target mood dysregulations.
c. Antidepressants: Selective-serotonin reuptake inhibitors (SSRIs) such as fluoxetine,
sertraline, citalopram are used to resolves depressive symptoms in the patient.

2. Psychotherapy should involves individual therapy, family therapy, and

psychoeducational programs aimed to develop the social skills and improve
cognitive functioning and also preventing relapse.
catatonia
 Catatonia

❖ Definitions:
➢ It is clinical syndrome characterized by striking behavioural abnormalities that may include
motoric immobility or excitement, profound negativism or echolalia or echopraxia.

❖ Epidemiology:
➢ It is an uncommon condition mostly seen in advanced primary mood or psychotic illnesses.
➢ 25%-50% are related to mood disorders (major depressive episode, recurrent, with
catatonic features), approximately 10% are associated with schizophrenia.

❖ Aetiology:
➢ Neurological disorders (nonconvulsive status epilepticus & head trauma)
➢ Infections (encephalitis)
➢ Metabolic disturbances (hepatic encephalopathy, hyponatremia & hypercalcemia)
➢ Medications (corticosteroids, immunosuppressants & antipsychotic)
 DSM-5 Diagnostic Criteria
Catatonia associated with Catatonic disorder due to another medical Unspecified catatonia
another mental disorder condition

The clinical picture is A. The clinical picture is dominated by three (or This category applies to presentations
dominated by three (or more) of more) of the psychomotor symptoms in which symptoms characteristic of
the psychomotor symptoms: catatonia:
B. There is evidence from the history, physical
examination, or laboratory findings that the
1. Stupor 1) Cause clinically significant
disturbance is the direct pathophysiological
2. Catalepsy consequence of another medical condition. distress or impairment in social,
occupational, or other important
3. Waxy flexibility
C. The disturbance is not better explained by areas of functioning
4. Mutism
another mental disorder (e.g., a manic
5. Negativism episode). 2) Either the nature of underlying
6. Posturing mental disorder or other medical
7. Mannerism D. The disturbance does not occur exclusively condition is unclear
during the course of a delirium.
8. Stereotypy
9. Agitation E. The disturbance causes clinically significant 3) Full criteria for catatonia are not
distress or impairment in social, occupational, met
10. Grimacing
11. Echolalia or other important areas of functioning
4) There is insufficient information
12. Echopraxia to make a more specific
diagnosis.
 Clinical Picture

The clinical picture is dominated by three (or more) of the following symptoms:

1. Stupor - no psychomotor activity, not actively relating to environment

2. Catalepsy - passive induction of posture held against gravity

3. Waxy flexibility - slight, even resistance to positioning by examiner

4. Mutism - no or very little verbal response to external stimuli

5. Negativism - opposition or no response to external stimuli

6. Posturing - spontaneous and active maintenance of a posture against gravity

 Clinical Picture (cont’d)

7. Mannerism - odd, circumstantial caricature of

normal movements

8. Stereotype - repetitive, abnormally frequent, non-

goal directed movements

9. Agitation, not influenced by external stimuli

10. Grimacing

11. Echolalia - mimicking others’ speech

12. Echopraxia - mimicking another’s movement

Relevant History
● Oftentimes patients cannot provide a coherent
history
● Ask about possible precipitating events, including
infection, trauma, and exposure to toxins and
other substances
● Inquire about any previous similar episodes of
catatonia;
○ Determine whether the precipitating events of the
earlier episode are present in the current episode, and

○ Record any interventions that relieved catatonia

previously
 Relevant History (cont’d)

● Exposure to neuroleptics and other substances associated with catatonia;

catatonia and neuroleptic malignant syndrome (NMS) may follow the
administration of neuroleptic medications
● Identify any comorbid disorders, including schizophrenia, mood
disorders, psychological stressors, medical conditions, and obstetric
conditions
● Diagnosis of catatonic disorder made only if there is evidence that the
condition is due to the physiological effects of a general medical condition
 Pathogenesis

Reduced GABA-A Dysfunctional

Glutamate
receptor activity dopamine metabolism

In the right lateral Data has been

Glutamatergic
orbitofrontal right inconsistent, but evidence
abnormalities in the
posterior parietal cortex, of sudden and massive
basal ganglia have been
which explain motor and dopamine blockade in
suggested as a driver for
behavioural symptoms. striatal dopaminergic
catatonia-related
Explains efficacy of system explains why
glutamate hyperactivity
benzodiazepines in 70% antipsychotics such as
of patients haloperidol exacerbates

Catatonia
 Management
Management

Treatment

● Admit the patient (if required).

● Maintain fluid and nutrient intake with intravenous lines or feeding tubes.
● Identify and correct the underlying medical or pharmacological cause.
● Benzodiazepines
● Electroconvulsive therapy (ECT)
Psychosis
nos, other
specified
psychosis
 Applying Psychosis NOS

1. Symptoms presented are characteristic of schizophrenia spectrum &

other psychotic disorders (SSOPD).

2. Clinically significant distress/ impairments of functioning

predominate (social, occupational, cognitive, etc.)

3. However, the full criteria for any of the disorders in SSOPD

diagnostic class is not met.
 Other specified SSOPD

- Application:
1. Clinician chooses to specify reason why presentation does not
meet diagnostic criteria SSOPD.
2. Recording “other specified SSOPD” followed by specific reason.

- Example of presentations:
1. Persistent auditory hallucinations occurring w/o other features.
2. Delusions with significant overlapping mood episodes.
3. Attenuated psychosis syndrome.
4. Delusional symptoms in partner of individual with delusional disorder.
 Unspecified SSOPD

- Application:
1. Clinician chooses not, or is unable, to specify reason why symptoms do
not match any other diagnostic criteria.

- Examples:
1. Emergency room setting.
2. Symptoms are not fully present to fulfill specific diagnostic criteria at
time of evaluation.
3. Insufficient history, despite presenting with ≥1 psychotic symptoms.
 Treating Psychosis NOS

● Not specified in DSM-V.

● Accurate diagnosis to be assigned before starting treatment (non-acute
psychotic episodes).

● Patients presenting with psychotic symptoms to the ER with unclear

etiology?
- Sedation with anti-psychotics & benzodiazepines
- Eg: IM haloperidol + lorazepam/ promethazine
Thank you!!!