Psychotic Disorders

Psychotic Disorders Schizophrenia Delusional D/O Schizophreniform D/O Brief Psychotic D/O Schizoaffective D/O Shared Psychotic D/O

Schizophrenia: History • Symptoms identified as a cluster of problems in early psychiatric medicine • Emil Kraepelin • Dementia precox • Distinct cognitive process & early onset • Differentiated these symptoms from manic depressive psychosis • Eugen Bleuler • Schizophrenia • Schism between thought, emotions and behavior • Current thought is that schizophrenia is a cluster of disorders, rather than one monolithic disease

Schizophrenia: Epidemiology & Etiology • There are several working theories regarding the development of this order. The following are a few current thoughts: • Viral Infections • Worldwide, most persons with Schizophrenia are born in the late winter & early spring. One hypothesis is that the D/O results from a seasonal-based viral infection during the summer months.

Schizophrenia: Epidemiology & Etiology • In addition, there are geographical pockets of Schizophrenia, mostly in urban areas. This also supports the hypothesis of a viral infection (which is more likely to spread in densely populated areas). There is a virtual absence of Schizophrenia in cities with a population of less than 10,000. Rates are much higher in cities with 1 million+ population • Genetic Factors • Children of parents with Schizophrenia are 10 times more likely to develop the disorder

Schizophrenia: Epidemiology & Etiology • Social Causation • There are higher rates of Schizophrenia in industrialized countries, where there is a disproportionate number of those with this illness in lower socio-economic classes

Schizophrenia: Other issues • Medical Illness • Higher mortality and rate form accidents and natural causes • Suicide risk • 15% • Risk factors include • White • Male • Socially isolated • Under age 45

Schizophrenia: Other issues • Substance use • Cigarettes • Nicotine has an affect on the receptors in the brain which reduce the perceptions of external stimuli, and may have an affect on the positive symptoms Schizophrenia • Common co-morbidity with other substance abuse

Schizophrenia: Other issues • Socio-economic • Downward drift hypothesis • Those with this illness tend to fall into, or fail to rise out of, lower socio-economic circumstances • Loss of productivity • The onset of Schizophrenia is usually in early adulthood. This is just after the individual has obtained job training (a cost) and is unable to perform in an employed capacity throughout the lifespan.

Schizophrenia: Other issues • Hospitalization • The cost of caring for those with Schizophrenia out-paces the costs for all cancer treatments combined. • Homelessness • One to two thirds of all homeless persons have Schizophrenia • Related to the policy of de-institutionalization

Schizophrenia: Diagnostic features No one symptom defines this disorder, therefore: • Taking a complete history is essential • Be aware that a client’s symptoms will change over time • Take into consideration the client’s educational, socio-economic and ethnic/cultural identity • Medical (especially neurological) disorders will have some of the same presenting symptoms as Schizophrenia

Schizophrenia: Diagnostic features • Characteristic symptoms include cognitive and emotional dysfunctions • Misperceptions • Inferential thinking • Language & communication • Behavioral monitoring • Affect • Fluency & productivity of speech • Hedonic capacity • Volition & drive • Attention • As well as problems with occupational and social functioning

Schizophrenia: Diagnostic features • Positive & negative symptoms • Positive symptoms are a distortion or an excess of normal functioning • “Psychotic dimension” • Thought content: delusions • Perceptions: hallucinations • “Disorganized dimension” • Language & thought process: disorganized speech • Self-monitoring of behavior: grossly disorganized or catatonic behavior

Schizophrenia: Diagnostic features • Negative symptoms are those which demonstrate a restriction in range & intensity of normal functioning • Affective flattening • Fluency and productivity of thought and speech • Initiation of goal directed behavior

Schizophrenia:Pre-morbid signs & symptoms • Often called the “prodromal” phase • This is a period of time prior to the full onset of the illness can be months to years), in which the client exhibits any of the following behaviors: • Quiet, passive, or introverted personality • No close friends • Enjoyed solitary activities, rather than being with friends • Somatic complaints • The prodromal period is much easier to identify after the onset of the illness, rather than before

Schizophrenia:Age, Gender & Culture • Equally prevalent in men & women • Onset is earlier in men (10 – 25 years old) • Onset in women is later (25 – 35 years), with a second peak in middle age • Men are more likely to be impaired by negative features • Women are more likely to have better social functioning • General prognosis is better for women

Schizophrenia:Age, Gender & Culture • Be careful in considering cultural, ethnic and religious backgrounds when screening for delusions and hallucinations • In addition, some cultures have norms about affective expression that may restrict eye contact between men and women, have differences in narrative expression of thought and speech, etc.

Schizophrenia:Course • Variable, with some moving into remission and others having a lifetime chronic course • Better prognosis is associated with the following: • Good premorbid functioning • Acute onset • Later age of onset • Absence of poor insight • Being female • Consistent medication compliance, etc • See page 309 in DSM

Schizophrenia:Differential Diagnosis • You know the drill… • General medial condition • Substance abuse • Dementia & delirium (differentiated by history) • Mood disorder with psychotic features & Schizoaffective D/O (psychotic features in Schizophrenia are absent of disturbances in mood)

Schizophrenia:Differential Diagnosis • Schizophreniform (duration) • Brief Psychotic D/O (duration) • Delusional D/O (Delusions are non-bizarre in this D/O, and there is an absence of hallucinations, disorganization and negative symptoms of Schizophrenia)

Schizophrenia:Diagnostic criteria • Two or more of the following, each for a significant period of time during a one month period (or less if successfully treated) • Delusions • Hallucinations • Disorganized speech • Grossly disorganized or catatonic behavior • Negative symptoms • Only one of the above is required if delusions are bizarre, or hallucinations consist of a voice making a running commentary on the person’s behavior, or two or more voices conversing with each other

Schizophrenia:Diagnostic criteria • Social & Occupational dysfunction • Duration: • One month of active phase symptoms (Criterion A), within a 6 month period of prodromal or residual symptoms (negative symptoms)

Schizophrenia:Course specifiers • Can be used one year after onset of active phase: • Episodic with Inter-episode Residual Symptoms • Specify if: With Prominent Negative Symptoms • Episodic with No Inter-episode Residual Symptoms • Continuous • Specify if: With Prominent Negative Symptoms

Schizophrenia:Paranoid Type 295.30 • Presence of prominent delusions or auditory hallucinations in the context of relative preservation of cognitive functioning and affect • Delusions are usually persecutory or grandiose, or may be of some other theme • Delusions are usually organized around a central theme • Hallucinations are related to the delusional theme • Symptoms of the Disorganized and Catatonic Type are not present

Schizophrenia:Paranoid Type 295.30 • May also experience • Anxiety • Aloofness • Anger • Argumentativeness • May also exhibit • Stilted or very formal style of communication • Extreme intensity in interpersonal relationships

Schizophrenia:Paranoid Type 295.30 • Onset is later in life • Characteristics are more stable over time. • Little or no impairment in cognitive testing • Better course • May be able to function independently and maintain a job

Schizophrenia:Disorganized type 295.10 • Identified by disorganized speech & behavior, and flat or inappropriate affect • Silliness & laughter not related to content • Grimacing, mannerisms, and other odd behaviors • Lack of goal oriented behavior interferes with Activities of Daily Living • Impairment on various neurological tests

Schizophrenia:Disorganized Type 295.30 • Absence of symptoms of Catatonic Type • Usually present with poor pre-morbid functioning • Early & insidious onset • Continuous course without significant remission • Poor prognosis; little capacity to care for self

Schizophrenia:Catatonic Type 295.20 • Marked psycho-motor disturbance • Motoric immobility • Excessive motor activity • Extreme negativism • Mutism • Peculiarities of voluntary movement • Echolalia & echopraxia • Motor activity is purposeless and is not in response to external stimuli

Schizophrenia:Catatonic Type 295.20 • Other motor symptoms • Waxy flexibility • Rigid posture, even after attempts to move the person • Grimacing • Bizarre postures • Needs to be protected from self-harm due to motor movements • This type once common in North America and Western Europe, is now rarely seen in these areas

Schizophrenia:Undifferentiated Type 295.9 • Meets the general criteria for Schizophrenia, but does not meet criteria for Paranoid, Disorganized or Catatonic Types

Schizophrenia:Residual Type 295.60 • There has been at least one episode of schizophrenia • Positive symptoms are no longer prominent • Negative symptoms remain • May be a transitional period between active phase and remission • Client may remain in this state for extended periods of time (years), with or without exacerbations of the active phase

Schizophreniform Disorder 295.40 • Diagnostic Features • Identical to Schizophrenia, except: • Duration • Total prodromal, active and residual phases last at least one month but not more than 6 months • Impaired social and occupational functioning is not a required criterion

Schizophreniform Disorder 295.40 • Diagnosis is automatically made in two situations • Applied in situations when the episode last between one and six months, from which the client has made a full recovery • Applied in situations in which a client may remain symptomatic, but for less than six months. In this situation, it would be classified as Provisional. If the client’s symptoms persist for more than six months, the diagnosis is changed to Schizophrenia

Schizophreniform Disorder 295.40 • Specifiers • With good prognostic features is used when two or more of the following are present: • The onset of prominent psychotic symptoms occurs within 4 weeks of the first noticeable change in behavior • Confusion or perplexity at the height of the active phase • Good premorbid social & occupational functioning • Absence of blunted or flat affect

Schizophreniform Disorder 295.40 • Specifiers • Without Good Prognostic Features • Used when two or more of the above features are not present

Schizophreniform Disorder 295.40 • Culture, Age & Gender • Same as Schizophrenia • Since those in “undeveloped” countries have a more rapid recovery, there will be a higher prevalence of Schizophreniform D/O rather than Schizophrenia • Course • Little information is available

Schizophreniform Disorder 295.40 • Familial Pattern • Little information, but there appears to be an increased risk for relatives of those with the D/O • Differential Diagnosis • The usual, plus • Brief Psychotic Disorder (lasts less than one month)

Schizoaffective D/O 295.470 • Diagnostic Features • A uninterrupted period of illness in which there is • a Major Depressive Episode. A Manic Episode. Or a Mixed Episode • The presence of Criterion A symptoms of Schizophrenia, and • At least two weeks of delusions or hallucinations in the absence of a disturbance in mood

Schizoaffective D/O 295.470 • A common pattern: • auditory hallucinations and persecutory delusions for two months, then the addition of a Major Depressive Episode for three months, then the cessation of the mood symptoms while the psychotic symptoms remain, then the cessation of the psychotic symptoms after another month.

Schizoaffective D/O 295.470 • Balancing the mood and psychotic symptoms • For this D/O, the Mood symptoms must be present for a substantial portion of the total episode. If they only last for a relatively brief period of time, the diagnosis is Schizophrenia.

Schizoaffective D/O 295.470 • Subtypes • Bipolar type: used when Manic or Mixed Episodes are part of the presentation • Depressive Type: used only when Major Depressive Episodes are part of the presentation

Schizoaffective D/O 295.470 • Course, Age & Gender • Typical onset is in early adulthood • Better prognosis than for Schizophrenia, but worse than for Mood D/O • Schizoaffective, Bipolar type is more common in young adults, while the Depressive Type is more common in older adults

Delusional Disorder 297.1 • Diagnostic Criteria • The presence of one or more non-bizarre delusions that persist for one month. • Auditory or visual hallucinations, if present, are not prominent • Tactile or olfactory hallucinations may be present if they pertain to the delusion • Other than the impact of the delusion, social and occupational functioning is not impaired and behavior is not obviously odd or bizarre

Delusional Disorder 297.1Subtypes • Erotomanic • Central theme: another person is in love with the client • Idealized romantic love rather than sexual attraction • The person about whom this delusion is held is usually of higher status • Efforts to contact the other person are common, (think “stalker”), although others may keep the delusion secret

Delusional Disorder 297.1Subtypes • Grandiose • Central theme: the person has great, but unrecognized, talent or has made some important discovery • Others may believe that they have a special relationship with someone important • May have religious content

Delusional Disorder 297.1Subtypes • Jealous Type: • Central theme: the person’s spouse/partner/lover is unfaithful • The belief is arrived out without due cause, and made upon incorrect inferences about small bits of information • The individual usually confronts the spouse, etc., and attempts to interfere in the imagined affair

Delusional Disorder 297.1Subtypes • Persecutory Type • Central theme: belief that one is being conspired against, cheated, spied upon, followed, poisoned, drugged, maliciously maligned, harassed or obstructed from long-term goals. • Small sights are exaggerated, and the focus of delusion is often on some injustice that must be remedied • Lots of court cases, lots of anger

Delusional Disorder 297.1Subtypes • Somatic Type • Central theme: bodily function • Most common is the idea that the person emits a foul odor from a body orifice, that there is an infestation of insects in or on the skin, that there is an internal parasite, or that a body part is not functioning (contrary to medical evidence)

Delusional Disorder 297.1Subtypes • Mixed Type • No one delusional theme predominates • Unspecified Type • Used when the dominant delusional belief is not clearly defined, or does not fit any of the other types

Delusional Disorder 297.1 • Culture, Age & Gender • A person’s culture and ethnicity must be taken into account when evaluation the presence of delusions • The jealous subtype is more common in men than women • There are no other age or gender differences

Psychotic Disorders