Schizophrenia and Other Psychotic Disorders

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Schizophrenia and Other Psychotic Disorders

• RCS 6931
• 6/14/07
• Steven R. Pruett, Ph.D.

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Psychosis

• Psychosis means out of touch with reality
• Generally implies one of five basic types of
  symptoms
• Delusions
• Hallucinations
• Disorganized Speech
• Disorganized Behavior
• Negative Symptoms

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Delusions

• Grandeur
• Guilt
• Ill Health
• Jealousy
• Passivity
• Persecution
• Poverty
• Reference
• Thought Control

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Hallucinations

• False sensory perception that occurs in absence
  of a related sensory stimulus.
• Hallucinations are usually considered abnormal
• Can affect any of the 5 senses
• Visual and Auditory are most common
• Individual must be fully conscious during false
  sensory perception for it to be considered a
  hallucination.
• Illusions ? Hallucinations

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Disorganized Speech

• Sometimes called Loose Associations
• Mental associations are not governed by reason
  instead they may go on rhymes, puns, and esoteric
  connections.
• Some disorganization is speech is common (listen
  to some politicians!) but in large people know
  what is intended.
• For disorganized speech to be psychotic it must
  seriously interfere with communication.

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Disorganized Behavior

• Behavior that is not goal-directed. E.g.
• Assuming maintaining postures
• Taking clothes off in public
• However, if the behavior is understandable then
  it would not be considered Disorganized Behavior.
• Burning bras in public during the early 70s

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Negative Symptoms

• Reduced range of expression of emotion
• Flat or blunted affect
• Reduced fluency or amount of speech
• Loss of will to do things (avolition)
• Called Negative because things are taken away
  from patient not added (like hallucinations or
  delusions).

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How to distinguish between psychotic disorders

• DSM use 4 criteria to distinguish between
  psychotic disorders
• Psychotic Symptoms
• Course of Illness
• Consequences of Illness
• Exclusions

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Psychotic Symptoms

• Remember what are psychotic symptoms
• Delusions
• Hallucinations
• Disorganized Speech
• Disorganized Behavior
• Negative Symptoms

• For a patient to be diagnosed as psychotic they
  have to have ONE of these symptoms
• For a patient to be diagnosed with Schizophrenia
  they must have at least TWO of these symptoms for
  at least 1 month

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Psychotic Symptoms

• Symptoms must exist for a significant times
  during a month.
• More days than not during month
• Several people independently observed on several
  days the patient having symptoms
• Symptoms occurred at times when they have a
  strong effect on patient and environment.

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Course of Illness

• Type of symptoms is usually determined by time,
  patterns, and other features of the disorder.
  Some of these are
• Duration
• Precipitating Factor
• Previous Course of Illness
• Premorbid Personality

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Consequences of Illness

• How has the illness affected the functioning of
  the individual?
• Socially?
• Occupationally?
• Academically?
• Financially?

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Exclusions

• Can the psychosis noted in the patient be
  attributed to any other Axis I disorder?
• Need to consider and rule out
• General Medical Condition
• Substance-related Disorder
• Mood Disorder

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Other Features

• There are items that are NOT in the DSM-IV-TR
  criteria that are important.
• Family History of Illness
• Response to Medication
• Age at Onset

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Pattern of Schizophrenia

• Before becoming ill, the patient was withdrawn or
  had a odd personality
• Illness begins gradually. At least 6 mos before
  the diagnosis is made behavior begins to change.
  This may include delusions or hallucinations or
  just odd beliefs.
• At least one month during these 6 mos the patient
  has to have been frankly psychotic with at least
  2 of the 5 basic symptoms.

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Pattern of Schizophrenia (cont)

• Illness causes significant problems with work and
  social functioning.
• Mood disorders, general medical conditions and
  substance use can be ruled out as probable causes
  of symptoms.
• It is rare that an individual makes a complete
  recovery (however, some recovery is likely)

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Issues in Schizophrenia

• Frequency
• Relatively common disorder (1 of general
  population)
• Chronicity
• The course of the disease is usually lifelong
• Severity
• Effects on social and occupational functioning is
  profound
• Management
• Most cases require psychotropic medications for
  the remainder of life this carries various
  risks.

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Common Symptoms

• Cognitive Dysfunction
• Distractibility and disorientation
• Dysphoria
• Anger, anxiety, depression
• Absence of Insight
• Frequently believe they are not ill and refuse to
  take medications
• Sleep disturbances
• Frequently due to hallucinations delusions
• Suicide
• About 10 of people with schizophrenia
  (frequently newly diagnosed) commit suicide.

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Diagnosis of Schizophrenia

• Its important to be accurate about the diagnosis
  of Schizophrenia
• Treatment is necessary
• Strong stigma is associated with the diagnosis
• Basic Criteria for all forms of Schizophrenia
• Morrison p. 144-145 DSM-IV-TR p. 312-313

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Schizophrenia Subtypes

• Paranoid Type
• Disorganized Type
• Catatonic Type
• Undifferentiated Type
• Residual Type

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Paranoid Type 295.30

• Must meet all basic criteria
• Preoccupation with delusions or frequent auditory
  hallucinations
• NO symptoms of
• Disorganized speech
• Disorganized behavior
• Inappropriate or flat affect
• Catatonic behavior

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Disorganized Type 295.10

• Used to be called hebephrenia
• Must meet all basic criteria
• Most psychotic of all subtypes
• Disorganized behavior
• Disorganized speech
• Flat or inappropriate affect

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Catatonic Type 295.20

• Not that common of a subtype anymore
• Must meet all basic criteria
• Must have at least 2 catatonic symptoms
• Stupor/motor immobility (catalepsy/waxy
  inflexibility)
• Non purposeful hyperactivity (not influenced by
  external stimuli)
• Mutism or marked negativism
• Peculiar behavior
• Posturing, stereotypies, mannerisms, or grimacing
• Echolalia or echopraxia

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Undifferentiated Type 295.90

• Diagnosis of exclusion
• Schizophrenia NOS?
• Must meet all basic criteria
• Cannot meet the criteria for other subtypes

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Residual Type 295.60

• Seldom used in clinical practice
• Patient at one time met the criteria for one of
  the subtypes of Schizophrenia.
• Patient no longer has pronounced symptoms
• Patient is still ill usually with negative
  symptoms or some left over odd beliefs,
  hallucinations, odd speech, or peculiar behavior.

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Schizophrenic like conditions

• Schizophreniform Disorder 295.40
• Looks like Schizophrenia and may very well be
  Schizophrenia, but we dont yet know.
• Same diagnostic criteria as basic Schizophrenia
  but
• there is no diagnostic criteria for dysfunction
  (doesnt require interference with patients
  life), or
• Symptoms may be present from 1 to 6 months (vs.
  more than 6 mos for Schizophrenia).

• Schizoaffective Disorder 295.70
• Can be very confusing.
• Must criterion A for basic Schizophrenia for at
  least 1 month.
• Must have delusions or hallucinations without
  major mood symptoms for 2 weeks or more.
• Mood symptoms meet criteria for Major Depressive,
  Manic, or Mixed Episode for a substantial
  period of the total illness.

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Other Psychotic Disorders

• Delusional Disorder 297.1
• Must have a nonbizarre delusion for at least 1
  mo.
• Brief Psychotic Disorder 298.8
• Have been psychotic for at least one day and have
  returned to normal within a month.
• Shared Psychotic Disorder 297.3
• Very rare
• One individual is individually psychotic and
  another buys into the psychosis by close
  association.

• Psychotic Disorder due to a General Medical
  Condition 293.8x
• Has a major medical problem but symptoms cant be
  explained by delirium (e.g. brain cancer)
• Substance-Induced Psychotic Disorder
• With delusions
• Alcohol 291.5
• All others 292.11
• With hallucinations
• Alcohol 291.3
• All others 292.12
• Psychotic Disorder NOS 298.9
• Other symptoms that dont meet the criteria for
  other psychotic conditions