Schizophrenia and other Psychotic Disorder

• Schizophrenia spectrum and other psychotic disorders

  Encompass schizophrenia, other psychotic disorders, and schizotypal (personality) disorder
• Psychotic disorders


  • Characterized by abnormalities in delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms
• Delusions


  Fixed beliefs that are not amenable to change in light of conflicting evidence
• Types of delusions


  • Persecutory
  • Referential
  • Grandiose
  • Erotomanic
  • Nihilistic
  • Somatic
• Hallucinations

  Perception-like experiences without external stimuli, vivid and clear with full impact, not under voluntary control, can occur in any sensory modality but auditory are most common in schizophrenia
• Disorganized thinking (inferred from speech)

  • Switching topics (derailment)
  • Tangential or unrelated answers to questions (tangentiality)
  • Severe linguistic disorganization (incoherence or "word salad")
  • Mild disorganization is common but must impair communication substantially to be significant
• Grossly disorganized or abnormal motor behavior


  • Childish silliness
  • Unpredictable agitation
  • Affecting goal-directed activities
• Catatonic behavior


  • Decreased reactivity to the environment
  • Resistance to instructions (negativism)
  • Maintaining rigid or bizarre postures
  • Complete lack of responses (mutism and stupor)
  • Purposeless excessive motor activity (catatonic excitement)
  • Stereotyped movements
• Negative symptoms


  • Diminished emotional expression
  • Avolition
  • Alogia
  • Anhedonia
  • Asociality
• Schizotypal personality disorder


  Pervasive pattern of social and interpersonal deficits, including reduced capacity for close relationships, cognitive or perceptual distortions, and eccentric behaviors, usually begins by early adulthood but may appear in childhood or adolescence, abnormalities of beliefs, thinking, and perception below the threshold for psychotic disorder diagnosis
• Delusional disorder


  Characterized by at least 1 month of delusions without other psychotic symptoms
• Brief psychotic disorder


  Lasts more than 1 day and remits by 1 month
• Schizophreniform disorder


  Symptomatic presentation similar to schizophrenia but lasts less than 6 months, without a decline in functioning requirement
• Schizophrenia

  Lasts for at least 6 months and includes at least 1 month of active-phase symptoms
• Schizoaffective disorder


  Features mood episodes and active-phase symptoms of schizophrenia, with or without prominent mood symptoms
• Substance/medication-induced psychotic disorder

  Psychotic symptoms result directly from substance abuse, medication, or toxin exposure, ceasing after removal of the agent
• Psychotic disorder due to another medical condition

  Psychotic symptoms result from another medical condition
• Catatonia


  Can occur in various disorders including neurodevelopmental, psychotic, bipolar, depressive, and other mental disorders, includes catatonia associated with another mental disorder, catatonic disorder due to another medical condition, and unspecified catatonia
• Other specified and unspecified schizophrenia spectrum and other psychotic disorders

  Included for classifying psychotic presentations not meeting criteria for specific disorders or with inadequate information
• Delusional disorder


  The essential feature is the presence of one or more delusions that persist for at least 1 month, with no history of meeting criteria for schizophrenia, functioning is not markedly impaired, and behavior is not obviously bizarre or odd
• Subtypes of delusional disorder

  • Erotomanic
  • Grandiose
  • Jealous
  • Persecutory
  • Somatic
  • Mixed
  • Unspecified
• Brief psychotic disorder


  Presence of one or more of the following symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, duration of an episode is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning
• Brief psychotic disorder may account for 2%-7% of cases of first-onset psychosis in several countries
• Development and course of brief psychotic disorder

  May manifest in adolescence or early adulthood, with onset possible at any age, typically occurring around the mid-30s, requires full remission of symptoms and return to premorbid functioning within 1 month
• Brief psychotic disorder (without marked stressor)


  Symptoms do not occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual's culture
• Brief psychotic disorder (with peripartum onset)


  Onset is during pregnancy or within 4 weeks postpartum
• Specifiers for brief psychotic disorder

  • With catatonia
  • Specify current severity
• Brief psychotic disorder


  • Manifests in adolescence or early adulthood, with onset possible at any age, typically occurring around the mid-30s
  • Requires full remission of symptoms and return to premorbid functioning within 1 month of onset, though symptoms may be very brief in some cases (e.g., a few days)
  • Despite reaching full remission within 1 month, over 50% of individuals may experience a relapse
  • Despite the possibility of relapse, most individuals have favorable outcomes in terms of social functioning and symptomatology
• Associated features of brief psychotic disorder

  • Emotional turmoil or overwhelming confusion
  • Rapid shifts from one intense affect to another
  • Severe impairment despite the brief duration of the disturbance
  • Supervision often required to ensure basic needs are met and to prevent harmful actions based on delusions or poor judgment
  • Increased risk of suicidal behavior, especially during the acute episode
• Culture-related diagnostic issues for brief psychotic disorder


  • Symptoms of brief psychotic disorder must be distinguished from culturally sanctioned response patterns
  • Cultural and religious background must be considered when evaluating whether beliefs are delusional
• Differential diagnosis for brief psychotic disorder

  • Other medical conditions
  • Substance-related disorders
  • Depressive and bipolar disorders
  • Malingering and factitious disorders
  • Personality disorders
• Schizophreniform disorder


  The characteristic symptoms are identical to those of schizophrenia
• Diagnosis of schizophreniform disorder requires that the episode of the disorder lasts at least 1 month but less than 6 months
• Criteria for schizophreniform disorder

  • Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): Delusions, Hallucinations, Disorganized speech, Grossly disorganized or catatonic behavior, Negative symptoms
  • Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out
  • The disturbance is not attributable to the physiological effects of a substance or another medical condition
• Specifiers for schizophreniform disorder

  • With good prognostic features: Onset of prominent psychotic symptoms within 4 weeks, confusion or perplexity, good premorbid social and occupational functioning, absence of blunted or flat affect
  • Without good prognostic features: Two or more of the above features have not been present
  • With catatonia
• Incidence of schizophreniform disorder across sociocultural settings likely similar to schizophrenia
• In high-income countries like the US, incidence of schizophreniform disorder is low, possibly fivefold less than schizophrenia
• In lower-income countries, incidence of schizophreniform disorder may be higher, especially "with good prognostic features"
• In some settings, schizophreniform disorder may be as common as schizophrenia
• Development of schizophreniform disorder

  • About one-third of initial diagnoses recover within 6 months, with schizophreniform disorder as final diagnosis
  • Majority of remaining two-thirds eventually diagnosed with schizophrenia or schizoaffective disorder