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01A
August 10, 2017
SCHIZOPHRENIA, SCHIZOPHRENIFORM, BRIEF PSYCHOTIC & DELUSIONAL DISORDERS
Jose Gerardo Los Baños, M.D.
Department of Psychiatry
TOPIC OUTLINE o In the general sense: can be viewed as a mental disorder
I. Introduction that markedly interferes with a person’s capacity to
a. Psychosis & Psychotic Disorder meet life’s everyday demands.
b. Signs and Symptoms o In a specific sense: refers to a thought disorder in which
c. Key Features that Define Psychotic Disorders reality testing is grossly impaired.
II. Schizophrenia o Minor distortions of reality that involve relative
a. History judgment is exempt.
b. Etiology
o Traditionally emphasized as loss of reality testing and
c. Diagnostic Criteria
d. Diagnostic Features impairment in mental functioning which manifests as
e. Associated Features delusions, hallucinations, confusion, and impaired
f. Subtypes of Schizophrenia memory
g. Differential Diagnosis • May appear as a symptom of a number of mental disorders,
III. Schizophreniform Disorder including mood and personality disorders.
a. Diagnostic Criteria • Depending on the condition underlying the psychosis,
b. Diagnostic Features
symptoms may be constant or sporadic
c. Associated Features
d. Development & Course • Catatonia, rigidity/immobility or excessive motor activity
e. Risk & Prognostic Factors may be observed. Others present with activity that is
f. Differential Diagnosis unpredictable or inappropriate for the situation.
IV. Brief Psychotic Disorder • Can be a result of brain injury, disease or drug use.
a. Diagnostic Criteria • Biological and psychosocial factors, independent of each
b. Diagnostic Features other or interactively, depending on the specific disorder,
c. Associated Features
appear to be etiologic or at least contributory.
d. Development & Course
e. Risk & Prognostic Factors
f. Differential Diagnosis B. Signs & Symptoms
V. Delusional Disorder Hallucination
a. Diagnostic Criteria • False sensory perception not associated with real external
b. Diagnostic Features stimuli
c. Subtypes of Delusional Disorder
• May involve one or more senses: auditory (most common in
d. Development & Course
e. Differential Diagnosis schizophrenia), visual, somatic (cenesthetic), olfactory,
gustatory, tactile (haptic)
• These may also be:
o synesthetic
I. INTRODUCTION o command
• Few conditions are as misunderstood and feared as o congruent
psychosis, and so much more than the other mental o incongruent
disorders o hypnagogic
• So much so that mental disorder has for some even become o hypnopompic
synonymous with being psychotic § hypnagogic, hypnopompic – not necessarily
• Pejorative terms abound: schizo, psycho, in the vernacular, pathogenic; may be physiologic
sira ulo, may tililing, may topak and a lot more
• There is something with the affliction of the mind that scares Delusion
us much more so than afflictions of the body • False belief, based on incorrect inference about external
reality, not consistent with patient’s intelligence and
A. Psychosis & Psychotic Disorders cultural background
• PSYCHOSIS - Gross impairment in reality testing leading • cannot be corrected by reasoning
to incorrect evaluation of the accuracy of perception and • These may be:
thoughts thus making incorrect inferences about external o nihilistic
reality even in the face of contrary evidence o poverty
• DESCRIPTION: o somatic
o Behaviorally appreciable as severe impairment of social o paranoid
and personal functioning characterized by social o persecution
withdrawal and inability to perform the usual o grandeur
household and occupational roles o reference
o self-accusation
4. Grossly Disorganized or Abnormal Motor Behavior
Illusion • may manifest in a variety of ways ranging from child-like
• False sensory perception of real external stimuli "silliness" to unpredictable agitation
(compare this to hallucinations) • Problems may be noted in any form of goal-directed
• Other manifestations include disorganized speech wherein behavior, leading to difficulties in performing activities of
patients may ramble on in incoherent, nonsensical speech daily living.
patterns • CATATONIC BEHAVIOR
o marked decrease in reactivity to the environment
C. Key Features that Define Psychotic Disorders o Negativism, mutism, stupor, catatonic, excitement
o Although catatonia has historically been associated with
1. Delusion
schizophrenia, catatonic symptoms are non-specific and
• Are fixed beliefs that are not amenable to change in light of may occur in other mental disorders and medical
conflicting evidence conditions
• Deemed bizarre if they are clearly implausible and not
understandable to same- culture peers and do not derive
5. Negative Symptoms
from ordinary life experiences. Delusions that express a loss
of control over mind and body are generally considered • Two negative symptoms particularly prominent in
bizarre. schizophrenia:
o E.g. belief that outside force has removed his/her o Diminished emotional expression
internal organs and replaced them with someone else’s § reductions in the expression of emotions in the
organs without leaving any wounds or scars face, eye contact, intonation of speech (prosody)
o Thought withdrawal and movements of the hand, head and face that
o Thought insertion normally give an emotional response to speech.
o Delusions of control o Avolition - decrease in motivated self-initiated
• An example of nonbizarre delusion is the belief that one is purposeful activities
under surveillance by the police, despite lack of convincing • Other negative symptoms:
evidence o Alogia
• May include a variety of themes: o Anhedonia
o Persecutory, referentials, grandiose, erotomanic, o Associality
nihilistic and somatic delusions o Allergy
2. Hallucinations II. SCHIZOPHRENIA
• Perception-like experiences that occur without an external A. History
stimulus Emil Kraepelin
• May occur in any sensory modality • Dementia precox - a term that emphasized the change in
• Auditory hallucinations cognition (dementia) and early onset (precox) of the
o most common in Schizophrenia and related disorder disorder
o Usually experienced as voices, whether familiar or not, • Paranoia - persistent persecutory delusions
that are perceived as distinct from the individual’s own
thoughts. Eugene Bleuler
• must occur in the context of a clear sensorium; those that • coined the term schizophrenia replaced dementia precox in
occur while falling asleep (hypnagogic) or waking up the literature
(hypnopompic) are considered to be within the range of • chose the term to express the presence of schisms between
normal experience. thought, emotion, and behavior in patients with the disorder
• may be normal part of religious experience in certain • identified specific fundamental (or primary) symptoms of
cultural contexts schizophrenia (THE FOUR As)
o associational disturbances of thought, especially
3. Disorganized Thinking (Speech) looseness
• a formal thought disorder o affective disturbances
• typically inferred from the individual’s speech o autism
• derailment or loose associations o ambivalence
• tangentiality • Bleuler also identified accessory (secondary) symptoms,
• Rarely, incoherence or "word salad" which included those symptoms that Kraepelin saw as major
indicators of dementia precox
• Less severe disorganized thinking or speech may occur
during the prodromal and residual periods of schizophrenia. o Hallucinations
o delusions
• Doc Joge: It may be more accurate to use the term
Disorganized Speech than Disorganized Thought. Hindi
B. Etiology
naman kasi tayo mind-readers…there’s no way for us to know
the exact thoughts of a person. Stress-Diathesis Model
• A person may have specific vulnerability (diathesis) that • Reduced Symmetry
when acted on by a stressful influence, allows the symptoms o in several brain areas in schizophrenia, including the
of schizophrenia to develop. temporal, frontal, and occipital lobes
o believed by some investigators to originate during fetal
Genetic Factors life which is indicative of a disruption in brain
• The likelihood of a person having schizophrenia is correlated lateralization during neurodevelopment
with the closeness of the relationship to an affected relative • Limbic System
(e.g., first- or second-degree relative) o ↓ in the size of the region including the amygdala, the
• Most commonly implicated: 5q, 11q, 18q, 19p & the X hippocampus, and the parahippocampal gyrus
chromosome o Hippocampus is also functionally abnormal as indicated
• Also implicated: loci on chromosomes 6, 8, & 22 by glutamate transmission disturbances
• Prefrontal Cortex
Biochemical Factors (Neurotransmitters) o Anatomical abnormalities in the prefrontal cortex in
schizophrenia and functional deficits in the prefrontal
Dopamine • Dopamine Hypothesis brain imaging region have also been demonstrated
o Schizophrenia results from too • Thalamus
much dopaminergic activity o volume shrinkage/neuronal loss, in particular subnuclei
o ↑↑ dopamine = ↑ severity of • Basal Ganglia and Cerebellum
positive symptoms o many patients with schizophrenia show odd
Serotonin • Serotonin excess can possibly cause movements, even in the absence of medication-induced
both positive and negative symptoms movement disorders (e.g., tardive dyskinesia)
Norepinephrine • associated with anhedonia (impaired o movement disorders involving the basal ganglia (e.g.
capacity for emotional gratification Huntington's disease, Parkinson's disease) are the ones
and the decreased ability to experience most commonly associated with psychosis.
pleasure). • Neural Circuits
• A selective neuronal degeneration o Observation of the relationship among impaired
within the norepinephrine reward working memory performance, disrupted prefrontal
neural system could account for this neuronal integrity, altered prefrontal, cingulate, and
aspect of schizophrenic symptoms. inferior parietal cortex, and altered hippocampal blood
• Noradrenergic system modulates the flow provides strong support for disruption of the
dopaminergic system in such a way normal working memory neural circuit in patients with
that abnormalities of the schizophrenia
noradrenergic system predispose a • Brain Metabolism
patient to relapse frequently o Patients with schizophrenia had lower levels of
GABA • Some px have a loss of GABAergic phosphomonoester and inorganic phosphate and higher
neurons in the hippocampus → could levels of phosphodiester.
lead to hyperactivity of dopaminergic • Applied Electrophysiology
neurons o Many schizophrenia patients have abnormal records,
Glutamate • Implicated because ingestion of increased sensitivity to activation procedures,
phencyclidine, a glutamate agonist, decreased alpha activity, increased theta and delta
produces an acute syndrome similar activity, possibly more epileptiform activity than usual,
to schizophrenia. and possibly more left-sided abnormalities than usual
Acetylcholine & • ↓ muscarinic and nicotinic o They also exhibit an inability to filter out irrelevant
Nicotine receptors in schizophrenia sounds and are extremely sensitive to background noise
Neuropeptides • Substance P • Complex Partial Epilepsy
• Neurotensin o Schizophrenia-like psychoses have been reported to
o occur more frequently in patients with complex partial
Neuropathology seizures, especially seizures involving the temporal
lobes
• Primarily in limbic system and the basal ganglia
• Evoked Potentials
• Including neuropathological or neurochemical abnormalities o In patients with schizophrenia, the P300 has been
in the cerebral cortex, the thalamus, and the brainstem
reported to be statistically smaller than that in
• Loss of brain volume widely reported in schizophrenic comparison groups.
brains o Other evoked potentials reported to be abnormal in
o result from reduced density of the axons, dendrites, and patients with schizophrenia are the N100 and the
synapses that mediate associative functions of the brain contingent negative variation.
• Eye Movement Dysfunction
• Cerebral Ventricles o The inability to follow a moving visual target accurately
o lateral and third ventricular enlargement and some is the defining basis for the disorders of smooth visual
reduction in cortical volume pursuit and disinhibition of saccadic eye movements
o observed during the earliest stages of the disease seen in patients with schizophrenia
• Psychoneuroimmunology • As a result, the person’s identity
o Immunological abnormalities that have been associated never becomes secure.
with patients who have schizophrenia: Paul Federn • Defect in ego functions permits
§ decreased T-cell interleukin-2 production intense hostility and aggression to
§ reduced number and responsiveness of peripheral distort the mother-infant relationship,
lymphocytes which leads to eventual personality
§ abnormal cellular and humoral reactivity to disorganization and vulnerability to
neurons stress.
§ presence of brain-directed (anti-brain) antibodies Harry Stack • Schizophrenia as a disturbance in
• Psychoneuroendocrinology Sullivan interpersonal relatedness.
o One carefully done report, however, has correlated • Px's massive anxiety creates a sense of
persistent nonsuppression on the unrelatedness that is transformed into
dexamethasonesuppression test in schizophrenia with a parataxic distortions, which are
poor long-term outcome usually, but not always, persecutory.
o Some data suggest decreased concentrations of LH/FSH, • Schizophrenia is an adaptive method
perhaps correlated with age of onset and length of used to avoid panic, terror, and
illness. disintegration of the sense of self.
o Abnormalities that may be correlated with the presence
of negative symptoms:
Learning Theories
§ blunted release of prolactin and GH on GnRH or
TRH stimulation • Children who later have schizophrenia learn irrational
§ blunted release of growth hormone on reactions and ways of thinking by imitating parents who
apomorphine stimulation have their own significant emotional problems
• Poor interpersonal relationships of persons with
schizophrenia develop because of poor models for
learning during childhood.
Psychosocial and Psychoanalytic Theories
Family Dynamics
• In a study of British 4-year-old children, those who had a
• Psychoanalytic theory postulates that the various symptoms
poor mother-child relationship had a six-fold increase in the
of schizophrenia have symbolic meaning for individual
risk of developing schizophrenia
patients.
• Double Bind
• For example, fantasies of the world coming to an end may
o Concept formulated by Gregory Bateson and Donald
indicate a perception that a person's internal world has
Jackson to describe a hypothetical family in which
broken down. L
children receive conflicting parental messages about
• Feelings of inferiority are replaced by delusions of grandeur
their behavior, attitudes, and feelings.
and omnipotence.
o Bateson’s Hypothesis: children withdraw into a
• Hallucinations may be substitutes for a patient's inability to psychotic state to escape the unsolvable confusion of
deal with objective reality and may represent inner wishes
the double bind
or fears.
• Schisms and Skewed Families
• Delusions, like hallucinations, are regressive, restitutive o Abnormal patterns of family described by Theodore
attempts to create a new reality or to express hidden fears or
Lidz
impulses.
o Schism between the parents, one parent is overly close
to a child of the opposite gender.
Proponent Views o Skewed relationship between a child and one parent
Sigmund • Schizophrenia resulted from involves a power struggle between the parents and the
Freud developmental fixations that occurred resulting dominance of one parent.
earlier than those culminating in the o These dynamics stress the tenuous adaptive capacity of
development of neuroses. the person.
• These fixations produce defects in ego • Pseudomutual and Pseudohostile
development and Freud postulated o Described by Lyman Wynne
that such defects contributed to the o Some families suppress emotional expression by
symptoms of schizophrenia. consistently using pseudomutual or pseudohostile
Margaret • Due to distortions in the reciprocal verbal communication.
Mahler relationship between the infant and o In such families, a unique verbal communication
the mother, the child is unable to develops, and when a child leaves home and must relate
separate from, and progress beyond, to other persons, problems may arise.
the closeness and complete o The child's verbal communication may be
dependence that characterize the incomprehensible to outsiders.
mother-child relationship in the oral • Expressed emotion
phase of development.
o Parents or other caregivers may behave with overt § Acute episode - time period in which the symptom
criticism, hostility, and too much involvement toward a criteria are fulfilled.
person with schizophrenia is high o First episode, currently in partial remission:
§ Partial remission - period of time during which an
DIAGNOSTOC CRITERIA improvement after a previous episode is maintained
From DSM V: and in which the defining criteria of the disorder are
only partially fulfilled.
A. Two (or more) of the following, each present for a o First episode, currently in full remission:
significant portion of time during a 1-month period (or less § Full remission - period of time after a previous
episode during which no disorder-specific symptoms
if successfully treated). At least one of these must be (1),
are present.
(2), or (3):
o Multiple episodes, currently in acute episode:
1. Delusions
§ Multiple episodes may be determined after a
2. Hallucinations minimum of two episodes (i.e., after a first episode, a
3. Disorganized speech (e.g., frequent derailment or remission and a minimum of one relapse).
incoherence) o Multiple episodes, currently in partial remission
4. Grossly disorganized or catatonic behavior o Multiple episodes, currently in full remission
5. Negative symptoms (i.e., diminished emotional o Continuous:
expression or avolition) § Symptoms fulfilling the diagnostic symptom criteria
B. For a significant portion of the time since the onset of the of the disorder are remaining for the majority of the
disturbance, level of functioning in one or more major illness course, with subthreshold symptom periods
areas, such as work, interpersonal relations, or self-care, is being very brief relative to the overall course.
markedly below the level achieved prior to the onset o Unspecified
(or when the onset is in childhood or adolescent, there is
failure to achieve expected level of interpersonal, academic, Specify if:
or occupational functioning). o With catatonia – Catatonic behavior is a marked
C. Continuous signs of the disturbance persist for at least decrease in reactivity to the environment.
6 months. This 6-month period must include at least 1
month of symptoms (or less if successfully treated) that Specify current severity:
meet Crtierion A (i.e., active-phase symptoms) and may • Severity is rated by a quantitative assessment of the primary
include periods of prodromal or residual symptoms. During symptoms of psychosis, including
these prodromal and residual periods, the signs of the o Delusions
disturbance may be manifested by only negative symptoms o Hallucinations
or by two or more symptoms listed in Criterion A present in o Disorganized speech
an attenuated form (e.g. odd belief, unusual perceptual o Abnormal psychomotor behavior, and
experiences). o Negative symptoms.
D. Schizoaffective disorder and depressive or bipolar disorder • Each of these symptoms may be rated for its current severity
with psychotic features have been ruled out because either (most severe in the last 7 days) on a 5-point scale ranging
1. no major depressive or manic episodes have occurred from 0 (not present) to 4 (present and severe).
concurrently with the active-phase symptoms, or Note: Diagnosis of schizophrenia can be made without using this
2. if mood episodes have occurred during active-phase severity specifier.
symptoms, they have been present for a minority of
the total duration of the active and residual periods of
the illness.
DIAGNOSTIC FEATURES
E. The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or From DSM V:
another medical condition.
F. If there is a history of autism spectrum disorder or a • Heterogeneous clinical syndrome
communication disorder of childhood onset, the additional • Characteristic symptoms involve a range of cognitive,
diagnosis of schizophrenia is made only if prominent behavioral, and emotional dysfunctions
delusions or hallucinations, in addition to the other • NO single symptom is pathognomonic.
required symptoms of schizophrenia, are also present for at • The diagnosis involves recognition of constellation of
least 1 month (or less if successfully treated). signs and symptoms associated with impaired
occupational or social functioning.
Specify if: • At least two Criterion A symptoms must be present for
a significant portion of time during a 1-month period or
• The following course specifiers are only to be used
longer.
after a 1-year duration of the disorder and if they are
not in contradiction to the diagnostic course criteria. • At least one of these symptoms must be the clear
o First episode, currently in acute episode: presence of delusions (Criterion A1), hallucinations
§ First manifestation of the disorder meeting the (Criterion A2), or disorganized speech (Criterion A3).
defining diagnostic symptom and time criteria. Grossly disorganized or catatonic behavior (Criterion
A4) and negative symptoms (Criterion A5) may also o Most common predictor of non-adherence to
be present. treatment, and it predicts higher relapse rates,
• Schizophrenia involves impairment in one or more major increased number of involuntary treatments, poorer
areas of functioning (Criterion B). psychosocial functioning, aggression, and a poorer
• If the disturbance begins in childhood or adolescence, the course of illness.
expected level of function is not attained.
• Some signs of the disturbance must persist for a • Hostility and aggression can be associated with
continuous period of at least 6 months (Criterion C). schizophrenia, although spontaneous or random assault is
• Prodromal symptoms often precede the active phase, uncommon.
and residual symptoms may follow it, characterized by Aggression is more frequent for:
mild or subthreshold forms of hallucinations or delusions. o Younger males
• Negative symptoms are common in the prodromal and o Individuals with a past history of violence, non-
residual phases and can be severe. adherence with treatment, substance abuse, and
• Individuals who had been socially active may become impulsivity.
withdrawn from previous routines. • Differences are evident in multiple brain regions between
• Such behaviors are often the first sign of a disorder. groups of healthy individuals and persons with
• Mood symptoms and full mood episodes are common in schizophrenia.
schizophrenia and may be concurrent with active-phase • Differences are evident in cellular architecture, white
symptomatology. matter connectivity, and gray matter volume in a variety
• However, a schizophrenia diagnosis requires the of regions such as the prefrontal and temporal cortices.
presence of delusions or hallucinations in the absence of • Reduced overall brain volume has been observed, as well
mood episodes. as increased brain volume reduction with age.
• Mood episodes, taken in total, should be present for only • Brain volume reductions with age are more pronounced in
a minority of the total duration of the active and residual individuals with schizophrenia than in healthy individuals.
periods of the illness. • Individuals with schizophrenia appear to differ from
individuals without the disorder in eyetracking and
electrophysiological indices.
ASSOCIATED FEATURES SUPPORTING DIAGNOSIS • urological soft signs common in individuals with
schizophrenia include
Patients with schizophrenia may present with:
• impairments in motor coordination, sensory integration, and
• Inappropriate affect
motor sequencing of complex movements
e.g., laughing in the absence of an appropriate stimulus
• Left-right confusion
• Dysphoric mood
In the form of depression, anxiety, or anger • Disinhibition of associated movements
• Disturbed sleep pattern
e.g., daytime sleeping and nighttime activity Minor physical anomalies of the face and limbs may occur.
• Lack of interest in eating or food refusal
• Depersonalization, derealization, and somatic concerns SUBTYPES OF SCHIZOPHRENIA
may occur and sometimes reach delusional proportions.
• Anxiety and phobias [NOTE: Subtypes of Schizophrenia, previously listed in DSM IV-
• Cognitive deficits are common and are strongly linked to TR, are no longer included in the DSM V.]
vocational and functional impairments.
o These can include decrements in declarative memory, DISORGANIZED TYPE. The disorganized type of schizophrenia is
working memory, language function, and other characterized by a marked regression to primitive, disinhibited,
executive functions, as well as slower processing and unorganized behavior and by the absence of symptoms that
speed. meet the criteria for the catatonic type.
o Abnormalities in sensory processing and inhibitory
capacity, as well as reductions in attention, are also
PARANOID TYPE. The paranoid type of schizophrenia is
found.
characterized by preoccupation with one or more delusions or
o Show social cognition deficits, including:
frequent auditory hallucinations. Characteristically with delusions
o Ability to infer the intentions of other people (theory of
of grandeur or persecution.
mind)
o May attend to and then interpret irrelevant events or
stimuli as meaningful, perhaps leading to the CATATONIC TYPE. The classic feature of the catatonic type is a
generation of explanatory delusions. marked disturbance in motor function; this disturbance may
o These impairments frequently persist during involve stupor, negativism, rigidity, excitement, or posturing.
symptomatic remission. Sometimes the patient shows a rapid alteration between extremes
• Anosognosia may be present in some individuals of excitement and stupor.
o Unawareness of illness is typically a symptom of
schizophrenia itself rather than a coping strategy. 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 • Socioeconomic and Cultural Factors
or of sufficient symptoms to meet the diagnosis of another type of • 2018B Trans:
schizophrenia. • Downward drift hypothesis Suggests that affected
persons move into, or fail to rise out of, a low
UNDIFFERENTIATED TYPE. Frequently, patients who clearly socioeconomic group because of this illness
have schizophrenia cannot be easily fit into one type or another. • Social causation hypothesis Proposes that stress
experienced by members of low socioeconomic groups
OTHER SUBTYPES: contribute to the development schizophrenia.
Bouffée Délirante (Acute Delusional Psychosis)
Latent ETIOLOGY
Oneiroid • STRESS-DIATHESIS MODEL
Paraphrenia o A person may have specific vulnerability (diathesis)
Pseudoneurotic Schizophrenia that when acted on by a stressful influence, allows
Simple Deteriorative Disorder (Simple Schizophrenia) the symptoms of schizophrenia to develop.
Postpsychotic Depressive Disorder of Schizophrenia • GENETIC FACTORS
Early-Onset Schizophrenia • The likelihood of a person having schizophrenia is
Late-Onset Schizophrenia correlated with the closeness of the relationship to an
Deficit Schizophrenia affected relative (e.g., first- or second-degree relative)
• Most commonly implicated: long arms of chromosome
5, 11 & 18, the short arm of chromosome 19 & the x
chromosome
EPIDEMIOLOGY (Kaplan 12th ed)
• Also implicated: loci on chromosomes 6, 8, & 22
• Gender and Age
• Schizophrenia is equally prevalent in men and women.
The two genders differ in the onset and course of BIOCHEMICAL FACTORS (Neurotransmitters)
illness. DOPAMINE Dopamine Hypothesis
• Onset is earlier in men than in women. o Schizophrenia results from
• Reproductive factors too much dopaminergic
• First-degree biological relatives of persons with activity
schizophrenia have a ten times greater risk for o éé dopamine = éseverity of
developing the disease than the general population. positive symptoms
• Medical illness SEROTONIN • Serotonin excess can possibly cause
• Persons with schizophrenia have a higher mortality rate both positive and negative
from accidents and natural causes than the general symptoms
population.
NOREPINEPHRINE • Associated with Anhedonia
• Infection and Birth Season
(impaired capacity for emotional
• Etiology of schizophrenia has been pointed to gratification and the decreased
o Gestational and birth complications ability to experience pleasure).
o Exposure to influenza epidemics • A selective neuronal degeneration
o Maternal starvation during pregnancy within the norepinephrine reward
o Rhesus factor incompatibility neural system could account for this
o Excess of winter births aspect of schizophrenic symptoms.
• Substance Abuse • Noradrenergic system modulates the
• Lifetime prevalence of any drug abuse: >50% dopaminergic system in such a way
• Nicotine that abnormalities of the
o Up to 90% schizophrenic may be nicotine- noradrenergic system predispose a
dependent patient to relapse frequently.
o Apart from smoking-associated mortality, GABA • Some px have a loss of GABAergic
nicotine decreases blood concentrations of neurons in the hippocampus à could
some antipsychotics. lead to hyperactivity of
o Nicotine administration appears to improve dopaminergic neurons
some cognitive impairments and Parkinsonism GLUTAMATE • Implicated because ingestion of
in schizophrenia, possibly d/t nicotine- phencyclidine, a glutamate agonist,
dependent activation of dopamine neurons produces an acute syndrome similar
• Population Density to schizophrenia.
• The prevalence of schizophrenia has been correlated ACETYLCHOLINE & êmuscarinic and nicotinic receptors in
with local population density in cities with populations NICOTINE schizophrenia
of more than 1 million people. NEURO-PEPTIDES • Substance P
• Neurotensin
7 of 15 HLTB, HCB, JAYPY, PDS, CGJS
Lecture Title
Schizophrenia is an adaptive method used to
NEUROPATHOLOGY (Kaplan 12th ed) avoid panic, terror, and disintegration of the
• Primarily in limbic system and the basal ganglia sense of self.
• Including neuropathological or neurochemical abnormalities in
the cerebral cortex, the thalamus, and the brainstem
• Loss of brain volume widely reported in schizophrenic brains LEARNING THEORIES
o Result from reduced density of the axons, dendrites and • Children who later have schizophrenia learn irrational reactions
synapses that mediate associative functions of the brain. and ways of thinking by imitating parents who have their own
significant emotional problems
PSYCHOSOCIAL AND PSYCHOANALYTIC THEORIES • Poor interpersonal relationships of persons with
• Psychoanalytic theory postulates that the various symptoms schizophrenia develop because of poor models for learning
of schizophrenia have symbolic meaning for individual during childhood.
patients.
• For example, fantasies of the world coming to an end may FAMILY DYNAMICS
indicate a perception that a person's internal world has • In a study of British 4-year-old children, those who had a poor
broken down. mother-child relationship had a six-fold increase in the risk of
• Feelings of inferiority are replaced by delusions of grandeur developing schizophrenia
and omnipotence.
• Double Bind
• Hallucinations may be substitutes for a patient's inability to
o Concept formulated by Gregory Bateson and Donald Jackson
deal with objective reality and may represent inner wishes
to describe a hypothetical family in which children receive
or fears.
conflicting parental messages about their behavior,
Delusions, like hallucinations, are regressive, restitutive attempts
attitudes, and feelings.
to create a new reality or to express hidden fears or impulses.
o Bateson’s Hypothesis:
Children withdraw into a psychotic state to escape the
PROPONENT VIEWS
unsolvable confusion of the double bind.
• Schisms and Skewed Families
Schizophrenia resulted from developmental
o Abnormal patterns of family described by Theodore
fixations that occurred earlier than those
Lidz
culminating in the development of neuroses.
o Schism between the parents, one parent is overly close
SIGMUND FREUD
to a child of the opposite gender.
These fixations produce defects in ego
o Skewed relationship between a child and one parent
development and Freud postulated that such
involves a power struggle between the parents and the
defects contributed to the symptoms of
resulting dominance of one parent.
schizophrenia.
o These dynamics stress the tenuous adaptive capacity of
the person.
Due to distortions in the reciprocal
relationship between the infant and the
• Pseudomutual and Pseudohostile
mother, the child is unable to separate from,
o Described by Lyman Wynne
and progress beyond, the closeness and
MARGARET o Some families suppress emotional expression by
complete dependence that characterize the
MAHLER consistently using pseudomutual or pseudohostile
mother-child relationship in the oral phase of
verbal communication.
development.
o In such families, a unique verbal communication
develops, and when a child leaves home and must relate
As a result, the person’s identity never
to other persons, problems may arise.
becomes secure.
o The child's verbal communication may be
incomprehensible to outsiders.
Defect in ego functions permits intense
hostility and aggression to distort the mother-
PAUL FEDERN • EXPRESSED EMOTION
infant relationship, which leads to eventual
personality disorganization and vulnerability Parents or other caregivers may behave with overt criticism,
to stress. hostility, and too much involvement toward a person with
schizophrenia is high.
Schizophrenia as a disturbance in
interpersonal relatedness. DEVELOPMENT AND COURSE
Onset of psychotic features:
HARRY STACK Between the late teens and the mid-30s
Px's massive anxiety creates a sense of •
SULLIVAN Onset prior to adolescence is rare
unrelatedness that is transformed into
parataxic distortions, which are usually, but • Peak age at onset for the first psychotic episode:
not always, persecutory. Males: Early- to mid-20s
Females: Late-20s
8 of 15 HLTB, HCB, JAYPY, PDS, CGJS
Lecture Title
Usually begins before age 25 − Intellectual and language alterations
Peak ages of onset: − Subtle motor delays
Men – 10 to 25 years • Late-onset cases - onset after age 40 years
Women – 25 to 35 years with second peak occurring in • Overrepresented by females, who may have married.
middle age (with 3 to 10% of women present with • Course is often characterized by a predominance of
disease onset after age 40) psychotic symptoms with preservation of affect and
• Onset may be abrupt or insidious social functioning.
• Majority manifest a slow & gradual development of variety • Such late-onset cases can still meet the diagnostic criteria for
of clinically significant S/Sx schizophrenia, but it is not yet clear whether this is the same
• Half of these complain of depressive symptoms. condition as schizophrenia diagnosed prior to mid-life (prior
• Earlier age at onset has traditionally been seen as a to age 55 years).
predictor of worse prognosis. •
• However, the effect of age at onset is likely related to gender, RISK AND PROGNOSTIC FACTORS
with males having worse premorbid adjustment, lower ENVIRONMENTAL
educational achievement, more prominent negative • Season of birth has been linked to the incidence of
symptoms and cognitive impairment, and in general a worse schizophrenia, including late winter/early spring in some
outcome. locations and summer for the deficit form of the disease.
• Impaired cognition is common, and alterations in cognition
• Incidence of schizophrenia and related disorders is higher for
are present during development and precede the emergence
children growing up in an urban environment and for some
of psychosis, taking the form of stable cognitive impairments
minority ethnic groups.
during adulthood.
• Cognitive impairments may persist when other symptoms
are in remission and contribute to the disability of the Features weighing toward good to poor prognosis in
disease. schizophrenia
• Predictors of course and outcome are largely unexplained, GOOD PROGNOSIS POOR PROGNOSIS
and course and outcome may not be reliably predicted. • Late onset • Young onset
• The course appears to be favorable in about 20% of those • Obvious precipitating • No precipitating factors
with schizophrenia, and a small number of individuals are factors • Insidious onset
reported to recover completely.
• Acute onset • Poor premorbid social, sexual
• However, most individuals with schizophrenia still require
formal or informal daily living supports, • Good premorbid social, and work histories
sexual, and work • Withdrawn, autistic behavior
• Many remain chronically ill, with exacerbations and
histories Single, divorced, widowed
remissions of active symptoms •
• Others have a course of progressive deterioration • Mood disorder • Poor support systems
symptoms (especially
• Psychotic symptoms tend to diminish over the life course, • Negative symptoms
perhaps in association with normal age-related declines in depressive disorders)
• Neurological SSx
dopamine activity. • Married
• Hx of perinatal trauma
• Negative symptoms • Family hx of mood
• No remissions in 3 years
− More closely related to prognosis than positive disorders
• Many relapses
symptoms • Good support systems
• Hx of assaultiveness
− Tend to be the most persistent • Positive symptoms
• Furthermore, cognitive deficits associated with the illness GENETIC AND PHYSIOLOGICAL
may not improve over the course of the illness.
• There is a strong contribution for genetic factors in
• Essential features of schizophrenia are the same in determining risks for schizophrenia; although most
childhood, but it is more difficult to make the diagnosis: individuals diagnosed with schizophrenia have no family
• Delusions & hallucinations may be less elaborate history of psychosis
• Visual hallucinations are more common and should be • Liability is conferred by a spectrum of risk alleles, common
distinguished from normal fantasy play and rare, with each allele contributing only a small fraction to
• Disorganized speech occurs in many disorders with the total population variance.
childhood onset
• The risk alleles identified to date are also associated with
• Autism spectrum disorder
other mental disorders [bipolar disorder, depression,a nd
• Attention-deficit/hyperactivity disorder autism spectrum disorder].
• Childhood-onset cases tend to resemble poor-outcome
• Pregnancy and birth complications with hypoxia and greater
adult cases, with gradual onset and prominent negative
paternal age are associated with a higher risk of
symptoms.
schizophrenia for developing fetus.
• Children who later receive the diagnosis of schizophrenia
are more likely to have experienced: • Other prenatal and perinatal adversities have been linked with
schizophrenia: stress, infection, malnutrition, maternal DM
− Nonspecific emotional-behavioral disturbances and
psychopathology and other medical conditions
• However, the vast majority of offspring with these risk factors Major depressive or bipolar disorder with psychotic or
do not develop schizophrenia. catatonic features
• If delusions or hallucinations occur exclusively during a
CULTURE-RELATED DIAGNOSTIC ISSUES major depressive or manic episode, the diagnosis is
• Cultural and socioeconomic factors must be considered. depressive or bipolar disorder with psychotic features.
• Ideas that appear to be delusional in one culture may be
Schizoaffective disorder
commonly held in another [e.g. withcraft]
• A diagnosis of schizoaffective disorder requires that a major
• Visual or auditory hallucinations with a religious content are a depressive or manic episode occur concurrently with the
normal part of religious experience [e.g. hearing God’s voice] active-phase symptoms and that the mood symptoms be
• Assessment of disorganized speech may be made difficult by present for a majority of the total duration of the active
linguistic variation in narrative styles across cultures. periods.
• Assessment of affect requires sensitivity to differences in
styles of emotional expression, eye contact & body language, Schizophreniform disorder and brief psychotic disorder
w/c vary across cultures. • These are of shorter duration than schizophrenia (which
• If the assessment is conducted in a language that is different requires 6 months of symptoms).
from the individual’s primary language, care must be taken to • Schizophreniform disorder, the disturbance is present less
ensure that alogia is not related to linguistic barriers. than 6 months
• In certain cultures: • Brief psychotic disorder, symptoms are present at least 1
o Distress may take the form of hallucinations or day but less than 1 month
pseudohallucinations
o Overvalued ideas that may present clinically similar to Delusional disorder
true psychosis but are actually normative to the • Can be distinguished from schizophrenia by the absence of
patient’s subgroup. the other symptoms characteristic of schizophrenia:
− Delusions
− Prominent auditory or visual hallucinations
GENDER-RELATED DIAGNOSTIC ISSUES − Disorganized speech
• General incidence of schizophrenia tends to be slightly lower − Grossly disorganized or catatonic behavior
in females, particularly among treated cases. − Negative symptoms
• Age at onset is later in females, with a second mid-life peak.
Schizotypal personality disorder
• Symptoms tend to be more affect-laden among females, and
• Schizotypal personality disorder may be distinguished from
there are more psychotic symptoms, as well as a greater
schizophrenia by subthreshold symptoms that are
propensity for psychotic symptoms to worsen in later life.
associated with persistent personality features.
• Other symptom differences include less frequent negative
symptoms and disorganization.
• Social functioning tends to remain better preserved in Obsessive-compulsive disorder and body dysmorphic
females. disorder
• Individuals with obsessive-compulsive disorder and body
SUICIDE RISK dysmorphic disorder may present with:
• Suicidal behavior is sometimes in response to command • Poor or absent insight
hallucinations to harm oneself or others • Preoccupations may reach delusional proportions
• Suicide risk remains high over the whole lifespan for males • These disorders are distinguished from schizophrenia by
and females their prominent:
o It may be especially high for younger males a with − Obsessions
comorbid substance abuse − Compulsions
• Other risk factors include: − Preoccupations with appearance or body odor
o Having depressive symptoms − Hoarding
o Feelings of hopelessness and being − Body-focused repetitive behaviors
unemployed
o Period after a psychotic episode or hospital Posttraumatic stress disorder
discharge • Flashbacks that have a hallucinatory quality
• Hypervigilance that may reach paranoid proportions
[Note: The details of Mental Status Examination and Psychological • But a traumatic event and characteristic symptom features
Testing can be found in Schizophrenia chapter of Kaplan. You can relating to reliving or reacting to the event are required to
also read them from previous trances. Additional info na lang kase make the diagnosis.
sila.]
Autism spectrum disorder or communication disorders
DIFFERENTIAL DIAGNOSIS
• Distinguished by their respective deficits in social category defines a group of patients, some of whom have a
interaction with repetitive and restricted behaviors and disorder similar to schizophrenia; others have a disorder
other cognitive and communication deficits. resembling a mood disorder.
• An individual with autism spectrum disorder or
communication disorder must have symptoms that meet full Diagnostic Criteria
criteria for schizophrenia, with prominent hallucinations or From DSM V:
delusions for at least 1 month, in order to be diagnosed with
schizophrenia as a comorbid condition. A. Two (or more) of the following, each present for a
significant portion of time during a 1-month period (or less
COMORBIDITY if successfully treated). At least one of these must be (1), (2)
Comorbidity with other Psychiatric Condition or (3):
• Comorbidity with substance-related disorders 1. Delusions
o High rates in schizophrenia 2. Hallucinations
o Over half of individuals with schizophrenia have 3. Disorganized speech
tobacco use disorder & smoke cigarettes regularly 4. Grossly disorganized or catatonic behavior
• Comorbidity with anxiety disorders, increasingly 5. Negative symptoms
recognized in schizophrenia • Diminished emotional expression / flat affect
o Rates of obsessive-compulsive disorder and panic • Avolition (lack of motivation)
disorder are elevated in individuals with schizophrenia • Alogia (poverty of speech)
compared with general population. • Anhedonia (inability to experience pleasure in
• Schizotypal or paranoid personality disorder may any positive stimulus)
sometimes precede the onset of schizophrenia. • Asociality (lack of interest for interpersonal
relationships or dealings with others)
SCHIZOPHRENIFORM DISORDER
B. An episode of the disorder lasts at least 1 month but less
• 1939: Gabriel Lanfeldt introduced the concept of
than 6 months.
schizophreniform disorder to describe a condition with a
sudden onset and benign course associated with mood • When the diagnosis must be made without waiting for
symptoms and clouding of consciousness. recovery, it should be qualified as “provisional.”
Epidemiology C. Schizoaffective disorder and depressive or bipolar disorder
with psychotic features have been ruled out because either
• Most common in adolescents and young adults and is less
1) No major depressive or manic episodes have occurred
than half as common as schizophrenia.
concurrently with the active-phase symptoms, or
• A fivefold greater rate of schizophreniform disorder has been
2) If mood episodes have occurred during active-phase
found in men than in women.
symptoms, they have been present for a minority of the
• A 1 year prevalence rate of 0.09% and a lifetime prevalence
total duration of the active and residual periods of the
rate of 0.11% have been reported.
illness.
• Several studies have shown that relatives of patients with
schizophreniform disorder are at high risk of having other
D. The disturbance is not attributable to the physiological
psychiatric disorders, but the distribution of disorders differs
effects of a substance (e.g., a drug of abuse, a medication) or
from the distribution seen in the relatives of patients with
another medical condition.
schizophrenia and bipolar disorders.
• Specifically, the relatives of patients with schizophreniform Specify if:
disorders are more likely to have mood disorders than are the
• With good prognostic features: This specifier requires
relatives of patients with schizophrenia.
the presence of at least two of the following features:
• In addition, the relatives of patients with schizophreniform o Onset of prominent psychotic symptoms within 4
disorder are more likely to have a diagnosis of a psychotic weeks of the first noticeable change in usual
mood disorder than are the relatives of patients with bipolar behavior or functioning;
disorders. o Confusion or perplexity
o Good premorbid social and occupational functioning
Etiology o Absence of blunted or flat affect.
• The cause of schizophreniform disorder is not known.
• Several studies have shown that patients with • Without good prognostic features: This specifier is
schizophreniform disorder, as a group, have more affective applied if two or more of the above features have not
symptoms (especially mania) and a better outcome than been present.
patients with schizophrenia.
• Also, the increased occurrence of mood disorders in the Specify if:
relatives of patients with schizophreniform disorder • With catatonia
indicates a relation to mood disorders.
• Thus, the biological and epidemiological data are most Specify current severity:
consistent with the hypothesis that the current diagnostic
• Severity is rated by a quantitative assessment of the individual diagnosis of schizophreniform disorder
primary symptoms of psychosis, including delusions, (provisional) recover within the 6-month period and
hallucinations, disorganized speech, abnormal schizophreniform disorder is their final diagnosis. The
psychomotor behavior, and negative symptoms. Each of majority of the remaining two-thirds of individuals will
this symptoms may be rated for its current severity (most eventually receive a diagnosis of schizophrenia or
severe in the last 7 days) on a 5-point scale ranging from schizoaffective disorder.
0 (not present) to 4 (present and severe).
Risk and Prognostic Factors
• Genetic and physiological
o Relatives of individuals with schizophreniform disorder
Diagnostic Features
have an increased risk for schizophrenia.
From DSM V:
Differential Diagnosis
• The characteristic symptoms of schizophreniform • Other mental disorder and medical conditions
disorder are identical to those of schizophrenia (Criterion o Psychotic disorder due to another medical
A). condition or its treatment
• Schizophreniform disorder is distinguished by its o Delirium or major neurocognitive disorder
difference in duration: the total duration of the illness, o Substance/medication-induced psychotic disorder
including prodromal, active, and residual phases, is at or delirium
least 1 month but less than 6 months (Criterion B). o Depressive or bipolar disorder with psychotic
• The duration requirement for schizophreniform disorder features
is intermediate between that for brief psychotic disorder, o Schizoaffective disorder
which lasts more than 1 day and remits by 1 month, and o Other specified or unspecified bipolar and related
schizophrenia, which lasts for at least 6 months. disorder
• The diagnosis of schizophreniform disorder is made o Depressive or bipolar disorder with catatonic
under two conditions: features
1) When an episode of illness lasts between 1 and 6 o Schizophrenia
months and the individual has already recovered, o Brief psychotic disorder
and o Delusional disorder
2) When an individual is symptomatic for less than the o Other specified or unspecified schizophrenia
6 months' duration required for the diagnosis of spectrum and other psychotic disorder
schizophrenia but has not yet recovered. o Schizotypal, schizoid or paranoid personality
• In this case, the diagnosis should be noted as disorders
"schizophreniform disorder (provisional)" because it is o Autism spectrum disorder
uncertain if the individual will recover from the o Disorders presenting in childhood with
disturbance within the 6-month period. disorganized speech
• If the disturbance persists beyond 6 months, the o Attention-deficit/hyperactivity disorder
diagnosis should be changed to schizophrenia. o Obsessive-compulsive disorder
• Another distinguishing feature of schizophreniform o Posttraumatic stress disorder
disorder is the lack of a criterion requiring impaired o Traumatic brain injury
social and occupational functioning. While such • It is important to first differentiate schizophreniform
impairments may potentially be present, they are not disorder from psychoses that can arise from medical
necessary for a diagnosis of schizophreniform disorder. conditions. This is accomplished by taking a detailed history
In addition to the five symptom domain areas identified in the and physical examination and, when indicated, performing
diagnostic criteria, the assessment of cognition, depression, laboratory tests or imaging studies.
and mania symptom domains is vital for making critically • A detailed history of medication use, including over-the-
important distinctions between the various schizophrenia counter medications and herbal products, is essential
spectrum and other psychotic disorders. because many therapeutic agents can also produce an acute
psychosis.
Associated Features • The duration of psychotic symptoms is one factor that
• There are no laboratory or psychometric tests for distinguishes schizophreniform disorder from other
schizophreniform disorder. syndromes.
• There are multiple brain regions where neuroimaging, • Distinguishing mood disorder with psychotic features from
neuropathological, and neuropsychological research has schizophreniform disorder is sometimes difficult.
indicated abnormalities, but none are diagnostic. Furthermore, schizophreniform disorder and schizophrenia
can be highly comorbid with mood and anxiety disorders.
Additional confounds are that mood symptoms, such as loss
Development and Course
of interest and pleasure, may be difficult to distinguish from
• The development of schizophreniform disorder is similar to negative symptoms, avolition, and anhedonia.
that of schizophrenia. About one-third of individuals with an
A thorough longitudinal history is important in elucidating the • The essential feature of brief psychotic disorder is a
diagnosis because the presence of psychotic symptoms disturbance that involves the sudden onset of at least one
exclusively during periods of mood disturbance is an indication of the following positive psychotic symptoms: delusions,
of a primary mood disorder. hallucinations, disorganized speech, or grossly abnormal
psychomotor behavior, including catatonia (Criterion A)
I. BRIEF PSYCHOTIC DISORDER • Sudden onset is defined as change from a nonpsychotic
• Defined as a psychotic condition that involves the sudden state to a clearly psychotic state within 2 weeks, usually
onset of psychotic symptoms that lasts 1 day or more but without a prodrome
less than 1 month • An episode of the disturbance lasts at least 1 day but less
• Remission is full – returns to premorbid level of functioning than 1 month, and the individual eventually has a full
return to the premorbid level of functioning (Criterion B)
A. Diagnostic Criteria • The disturbance is not explained by a depressive or
From DSM V: bipolar disorder with psychotic features, by schizoaffective
disorder or by schizophrenia
• Not attributable to the physiologic effects of a substance or
• Presence of one (or more) of the following symptoms. At another medical condition (Criterion C)
least one of these must be (1), (2), or (3):
1. Delusions
2. Hallucinations C. Associated Features Supporting Diagnosis
3. Disorganized speech (e.g., frequent derailment or • Typically experience emotional turmoil or overwhelming
incoherence) confusion
4. Grossly disorganized or catatonic behavior • May have rapid shifts from one intense affect to another
Note: Do not include a symptom if it is a culturally sanctioned • Although disturbance is brief, level of impairment may be
response severe
• Duration of an episode of the disturbance is at least 1 day o Supervision may be required to ensure that nutritional
but less than 1 month, with eventual full return to and hygienic needs are met
premorbid level of functioning • Increased risk of suicidal behavior particularly during the
• The disturbance is not better explained by major acute episode
depressive or bipolar disorder w/ psychotic features or
another psychotic disorder such as schizophrenia or D. Development and Course
catatonia o not attributable to the physiological effects of a • Brief psychotic disorder may appear in adolescence or early
substance (e.g., a drug of abuse, a medication) or another adulthood
medical condition • Onset can occur across the lifespan, with the average age at
onset being the mid-30s
Specify if: • Requires a full remission of all symptoms and an eventual
• With marked stressor(s) (brief reactive psychosis) full return to the premorbid level of functioning within 1
o Symptoms occur in response to events that, month of the onset of the disturbance
singly or together, would be markedly stressful
to almost anyone in similar circumstance in the E. Risk and Prognostic Factors
individual’s culture
• Preexisting personality disorder
• Without marked stressor(s)
o Schizotypal personality disorder
o Symptoms do not occur in response to events
o Borderline personality disorder
that, singly or together, would be markedly
• Traits
stressful to almost anyone in similar
o Perceptual dysregulation
circumstance in the individual’s culture.
o Suspiciousness
• With postpartum onset
o Onset is during pregnancy or 4 weeks
postpartum F. Differential Diagnosis
Specify if with catatonia • Other medical conditions
Specify current severity: o A variety of medical disorders can manifest with
psychotic symptoms of short duration
Rated by a quantitative assessment of the primary symptoms
§ Cushing’s syndrome
of psychosis, including delusions, hallucinations, disorganized
§ Brain tumor
speech, abnormal psychomotor behavior, and negative
• Substance-related disorders
symptoms
o A substance (e.g. a drug abuse or medication) is judged to
be etiologically related to the psychotic symptoms.
B. Diagnostic Features Laboratory tests may be helpful (e.g. urine testing for
From DSM V: alcohol screening)
• Depressive and bipolar disorders
o Diagnosis of brief psychotic disorder cannot be made
when it is better explained by a mood episode
• Other psychotic Disorders unfaithful.
o If psychotic symptoms persist for 1 month or longer the • Persecutory Type
diagnosis could be o This subtype applies when the central theme of the
§ Schizophreniform disorder delusion involves the individual’s belief that he or she is
§ Delusional disorder
being conspired against, cheated, spied on, followed,
§ Depressive disorder with psychotic features
§ Bipolar disorder with psychotic features poisoned or drugged, maliciously maligned, harassed,
• Malingering and factitious disorders or obstructed in the pursuit of long-term goals.
o May have the appearance of brief psychotic disorder, but • Somatic Type
in such cases there is evidence that the symptoms are o This subtype applies when the central theme of the
intentionally produced delusion involves bodily functions or sensations.
o When malingering involves apparently psychotic • Mixed Type
symptoms, there is usually evidence that the illness is
o This subtype applies when no one delusional theme
being feigned for an understandable goal
predominates.
• Personality disorders
o psychosocial stressors may precipitate brief periods of • Unspecified Type
psychotic symptoms. These symptoms are usually o This subtype applies when the dominant delusional
transient and do not warrant a separate diagnosis. If belief cannot be clearly determined or is not described
psychotic symptoms persist for at least 1 day, and in the specific types (e.g., referential delusions without a
additional diagnosis of brief psychotic disorder may be prominent persecutory or grandiose component).
appropriate
Specify if:
DELUSIONAL DISORDER
• With bizarre content
Diagnostic Criteria
o Delusions are deemed bizarre if they are clearly
From DSM V: implausible, not understandable, and not derived from
ordinary life experiences (e.g., an individual’s belief that
A. The presence of one (or more) delusions with a duration of a stranger has removed his or her internal organs and
one month or longer. replaced them with someone else’s organs without leaving
B. Criterion A for schizophrenia has never been met. any wounds or scars).
Note: Hallucinations, if present, are not prominent and are
related to the delusional theme (e.g., the sensation of being Specify if:
infested with insects associated with delusions of infestation). The following course specifiers are only to be used after a 1 –
C. Apart from the impact of the delusion(s) or its ramifications, year duration of the disorder:
functioning is not markedly impaired, and behavior is not • First episode, currently in acute episode
obviously bizarre or odd. o First manifestation of the disorder meeting the defining
D. If manic or major depressive episodes have occurred, these diagnostic symptom and time criteria.
have been brief relative to the duration of the delusional o An acute episode is a time period in which the symptom
periods. criteria are fulfilled.
E. The disturbance is not attributable to the physiological • First episode, currently in partial remission
effects of a substance or another medical condition and is not o Partial remission is a time period during which an
better explained by another mental disorder, such as body
improvement after a previous episode is maintained and in
dysmorphic disorder or obsessive-compulsive disorder.
which the defining criteria of the disorder are only partially
fulfilled.
Specify whether:
• First episode, currently in full remission
• Erotomanic Type
o Full remission is a period of time after a previous episode
o This subtype applies when the central theme of the
during which no disorder-specific symptoms are present.
delusion is that another person is in love with the
• Multiple episodes, currently in acute episode
individual.
• Multiple episodes, currently in partial remission
• Grandiose Type
• Multiple episodes, currently in full remission
o This subtype applies when the central theme of the
• Continuous
delusion is the conviction of having some great (but
o Symptoms fulfilling the diagnostic symptom criteria of
unrecognized) talent or insight or having made some
the disorder are remaining for the majority of the illness
important discovery.
course, with subthreshold symptom periods being very
• Jealous Type
brief relative to the overall course.
o This subtype applies when the central theme of the
• Unspecified
individual’s delusion is that his or her spouse or lover is
Specify current severity: • Delusional disorder has a significant familial relationship
• Severity is rated by a quantitative assessment of the primary with both schizophrenia and schizotypal personality
symptoms of psychosis, including delusions, hallucinations, disorder
disorganized speech, abnormal psychomotor behavior, and • The condition may be more prevalent in older individuals
negative symptoms. • A common characteristic of individuals with delusional
disorder is the apparent normality of their behavior and
• Each of these symptoms may be rated for its current severity
appearance when their delusional ideas are not being
(most severe in the last 7 days) on a 5-point scale ranging discussed or acted on.
from 0 (not present) to 4 (present and severe).
Note: Diagnosis of delusional disorder can be made without Differential Diagnosis
using this severity specifier. From DSM V:
Diagnostic Features A. Obsessive- compulsive and related disorders
From DSM V: • If an individual with OCD is completely convinced that
his or her OCD beliefs are true, then the diagnosis of
• Essential feature of delusional disorder is the presence of obsessive compulsive disorder, with absent
insight/delusional beliefs specifier, should be given
one or more delusions that persist for at least 1 month
rather than a diagnosis of delusional disorder.
(Criterion A). • Similarly, if an individual with body dysmorphic
• Diagnosis of delusional disorder is not given if the individual disorder (BDD) is completely convinced that his or her
has ever had a symptom presentation that met Criterion A BDD beliefs are true, then the diagnosis of body
for schizophrenia (Criterion B). dysmorphic disorder, with absent insight/delusional
• Apart from the direct impact of the delusions, impairments beliefs specifier, should be given rather than a diagnosis
in psychosocial functioning may be more circumscribed than of delusional disorder.
those seen in other psychotic disorders such as
B. Delirium, major neurocognitive disorder, psychotic
schizophrenia, and behavior is not obviously bizarre or odd disorder due to another medical condition, substance/
(Criterion C). medication induced disorder
• If mood episodes occur concurrently with the delusions, the • Individuals with these disorders may present with
total duration of these mood episodes is brief relative to the symptoms that suggest delusional disorder.
total duration of the delusional periods (Criterion D). • For example, simple persecutory delusions in the
• The delusions are not attributable to the physiological context of major neurocognitive disorder would be
effects of a substance (e.g., cocaine) or another medical diagnosed as major neurocognitive disorder, with
behavioral disturbance.
condition (e.g., Alzheimer's disease) and are not better
• A substance/ medication-induced psychotic disorder
explained by another mental disorder, such as body crosssectionally may be identical in symptomatology to
dysmorphic disorder or obsessive-compulsive disorder delusional disorder but can be distinguished by the
(Criterion E). chronological relationship of substance use to the onset
and remission of the delusional beliefs.
Subtypes of Delusional Disorder
Erotomanic Type C. Schizophrenia and schizophreniform disorder
• Delusional disorder can be distinguished from
• A delusion that another person is in love with the individual schizophrenia and schizophreniform disorder by the
• Usually of higher status but can be a complete stranger absence of the other characteristic symptoms of the
Grandiose Type active phase of schizophrenia.
• Conviction of having some great talent or insight of having
made some important discovery. D. Depressive and bipolar disorders and
Jealous Type schizoafferctive disorder
• A delusion that his or her spouse or lover is unfaithful. • May be distinguished from delusional disorder by the
Persecutory Type temporal relationship between mood disturbance &
delusions & by the severity of the mood symptoms
• Belief of being conspired against, cheated, spied,
followed, poisoned, maliciously maligned, harassed or
obstructed in the pursuit of long term goals.
References
Somatic Type
• Doc Joge’s PPT and lecture
• Involves bodily functions or sensations
• American Psychiatric Association. (2013). Diagnostic and
Statistical Manial of Mental Disorders (5th ed.). Washington,
Development and Course
D.C.
• Global function is generally better than that in schizophrenia LET’S GO BATCH 2019! 100% PROMOTION!
• A proportion of individuals go on to develop schizophrenia #2019KAKAYANIN #ROADTOCLERKSHIP