CAYME CHUA DAJALOS DAMASEN DE GUZMAN DELA CRUZ, A DELA CRUZ, J ESCONDO

PSYCHOTIC

Psychotic

delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. "impairment that grossly interferes with the capacity to meet ordinary demands of life." also previously been defined as a "loss of ego boundaries" or a "gross impairment in reality testing."

A. Essential Features:

SCHIZOPHRENIA

A chronic (persistent, reoccurring, long lasting) disorder. onset of Schizophrenia typically occurs between the late teens and the mid 3Os, with onset prior to adolescence rare. proportion of affected women is greater modal age at onset for men is between 18 and 25 years, and that for women is between 25 and the mid 30s.

The essential features of Schizophrenia are a mixture of characteristic signs and symptoms (both positive and negative) that have been present for a significant portion of time during a 1-month period (or for a shorter time if successfully treated), with some signs of the disorder persisting for at least 6 months.

These signs and symptoms are associated with marked social or occupational dysfunction. The disturbance is not better accounted for by Schizoaffective Disorder or a Mood Disorder with Psychotic Features and is not due to the direct physiological effects of a substance or a general medical condition.

Phases of Schizophrenia

Prodromal Phase
Refers

to the year before he sickness appears The early signs and symptoms of the disease before the characteristics symptoms appear People in the prodromal stage often isolate themselves, their school or work performance suffers, they may show signs of decreased motivation, loss og interest in activities and blunted emotions one cannot identify the prodromal stage until the active phase is reached.

Acute or Active Stage

The

time when the patient experiences the characteristic symptoms of Schizophrenia (e.g hallucinations, delusions, thought disturbances, etc) Indicates full development of the disorder Must last for at least a period of one (1) month (or less if successfully treated) to be diagnosed

Residual Stage
The

final stage The features are similar to the prodromal stage Patients may still experience the negative symptoms (such as disturbances in speech or lack of emotion) but without the more characteristics symptoms such as delusions

B. Signs and Symptoms:

The characteristics of Schizophrenia involve a range of cognitive and emotional dysfunctions. No single symptom is pathognomonic of Schizophrenia Positive symptoms: reflect an excess or distortion of normal functions Negative symptoms: which reflect a diminution or loss of normal functions

Positive symptoms Delusions Hallucinations

Negative symptoms Loosening of associations Overinclusiveness

Bizarre and inappropriate behaviors

Strange grimacing and posturing Ritual behavior Excessive silliness Aggressiveness Sexual inappropriateness

Neologisms
Blocking Clanging Echolalia Concreteness Alogia Blunted or flat affect Inappropriate affect Labile affect Anhedonia

Avolition

1. Biological

C. Different Perspectives

No pathognomonic structural or functional abnormality although numerous intriguing abnormalities that appear to be static exist. Hippocampal abnormalities and frontal lobe atrophy due to decreased blood flow: locations are suggestive of the behavioral disturbances found in schizophrenia

Dopamine hypothesis: (1) the discovery that antipsychotic drugs act to block postsynaptic dopamine receptors; (2) amphetamine increases brain dopamine activity such that when taken in high doses, mimic the symptoms of psychosis; (3) excessive amounts of dopamine is found in the brains (limbic system, basal ganglia) of schizophrenic patients Significant inherent component: the closer the relative, the greater the risk

Enlarged ventricles and lesser amounts of gray matter especially in the temporal and frontal lobe: accounts for the positive symptoms exhibited by patients with Schizophrenia Smaller hypothalamus: accounts for inability of patients with schizophrenia to screen irrelevant stimuli (somewhat related to deficiencies in orienting process of the cognitive perspective)

2. Social (Family and Environment) Perspective

Family

dynamics and turbulence play a major role in producing either relapse or remission. (double bind hypothesis, communication deviance, expressed emotion) Parenting style seems to have no major effect, although people with supportive parents do better than those with critical or hostile parents.

 Occurs

more frequently in urban populations and in lower socioeconomic groups. Poor environments do not cause the disorder, although they make it more intractable. Other factors that play an important role include social isolation and immigration related to social adversity, racial discrimination, family dysfunction, unemployment, and poor housing conditions.

3. Psychodynamic Perspective
Regression

to a state of primary narcissism: results to preoccupation in oneself and loss of contact with reality Dysfunctional family dynamics -> Schizophrenogenic mother: (FrommReichmann) a cold, rejecting, distant and dominating mother who causes schizophrenia

4. Behavioral Perspective

Operant reinforcement: due to disturbed family life and attentional difficulties, they find it difficult to attend to normal social cues and instead involve themselves in irrelevant cues which gets more attention and becomes reinforce of bizarre attitude.

5. Cognitive Theories
Deficiencies

in orienting responses: cause them to attend to irrelevant aspects and ignore relevant ones. Abnormal attributional processes: bias towards attributing negative life events to external causes and positive events to internal causes in cases when they perceive that something is a threat to themselves Lack a theory of mind (TOM): inability to understand the mental state and intentions of others.

D. Diagnostic Criteria

Characteristic symptoms: Two or more of the above mentioned, each present for much of the time during a one-month period (or less, if symptoms remitted with treatment). Social or occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset.

Significant duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if symptoms remitted with treatment). Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

* Subtypes:
295.30

Paranoid Type Most stable, least sever and most common. Usually develops later than other forms. A type of Schizophrenia in which the following criteria are met: Preoccupation with one or more delusions or frequent auditory hallucinations. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

 295.10

Disorganized Type The most severe subtype of Schizophrenia A type of Schizophrenia in which the following criteria are met: All of the following are prominent: disorganized speech disorganized behavior flat or inappropriate affect The criteria are not met for Catatonic Type.

295. 20 Catatonic Type A type of Schizophrenia in which the clinical picture is dominated by at least two of the following: Catatonic stupor: motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor Catatonic excitement: excessive motor activity (that is apparently purposeless and not influenced by external stimuli) Catatonic negativism and mutism: extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism Catatonic posturing: peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent

 295.

90 Undifferentiated Type A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

295.60 Residual Type A type of Schizophrenia in which the following criteria are met: Absence of prominent delusions, hallucinations, disorganized speech and grossly disorganized or catatonic behavior. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g. odd beliefs. unusual perceptual experiences).

* Specifiers
Episodic

With Interepisode Residual Symptoms: applies when the course is characterized by episodes in which Criterion A for Schizophrenia is met and there are clinically significant residual symptoms between the episodes. With Prominent Negative Symptoms can be added if prominent negative symptoms are present during these residual periods. EpisodicWith No lnterepisode Residual Symptoms: applies when the course is characterized by episodes in which Criterion A for Schizophrenia is met and there are no clinically significant residual symptoms between the episodes.

 Continuous:

applies when characteristic symptoms of Criterion A are met throughout all (or most) of the course. With Prominent Negative Symptoms can be added if prominent negative symptoms are also present. Single Episode In Partial Remission: applies when there has been a single episode in which Criterion A for Schizophrenia is met and some clinically significant residual symptoms remain. With Prominent Negative Symptoms can be added if these residual symptoms include prominent negative symptoms.

 Single

Episode In Full Remission: applies when there has been a single episode in which Criterion A for Schizophrenia has been met and no clinically significant residual symptoms remain. Other or Unspecified Pattern: used if another or an unspecified course pattern has been present.

295.40
SCHIZOPHRENIFO RM DISORDER

It is a time-limited illness wherein the sufferer has experienced at least two major symptoms of psychosis for longer than one month but fewer than six months.

Similar to schizophrenia except: the total duration of the illness and impaired social or occupational functioning during some part of the illness is not required.

A. Essential Features

Symptoms:
Positive

symptoms

- refers to a factor being present that does not normally occur - to an excess of some factor or behavior - includes: hallucinations, delusions, strange bodily movements or frozen movements (catatonic behavior), peculiar speech and bizarre or primitive behavior.

Negative symptoms - refers to an absence or deficiency of a factor that is usually at a reasonable level during normal functioning. - includes: avolition, affective flattening and alogia

The disorder occurs equally in men and women. - Men develop schizophreniform symptoms most often between the ages of 18 and 24, while symptoms most often appear in women between the ages of 24 and 35. Schizophreniform disorder is an acute illness.

B. Different Perspectives

Biological Perspective - can be genetic or hereditary - can also be due to brain chemistry - may have an imbalance of certain chemicals in the brain that can interfere with the transmission of messages, leading to symptoms. - brains structure play a prominent role in determining whether a person will develop the disorder

Sociocultural Perspective - evidence suggests that certain environmental factors such as poor social interactions or highly stressful events may trigger schizophreniform disorder in people who have inherited a tendency to develop the illness.

C. Diagnostic Criteria
A.

Characteristic symptoms: Two or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated) 1. Delusion 2. Hallucinations 3. Disorganized speech 4. Grossly Disorganized or catatonic behavior 5. Negative symptoms, i.e, affective flattening, alogia, or avolition

B. Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either: 1. No Major Depressive, Manic, or Mixed Episodes occurred concurrently with the active-phase symptoms. 2. If mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

C. Substance/general medical condition exclusion: the disturbance is not due to the direct physiological effects of the substance or a general medical condition. D. An episode of the disorder last at least 1 month but less than 6 months.

*Specify if:
With Good Prognostic Features: as evidence by two or more of the following:
1.

2.

3. 4.

Onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning Confusion or perplexity at the height of the psychotic episode Good premorbid social and occupational functioning Absence of blunted or flat affect

Without Good Prognostic Features: if two or more of the above feature have not been present.

298.8 BRIEF PSYCHOTIC DISORDER

A. Essential Features

Patients who experience an acute or brief psychotic episode lasting longer than one day but less than one month and that may or may not immediately follow an important life stress or a pregnancy(with postpartum onset.) Individuals with Brief Psychotic Disorder typically experience emotional turmoil or overwhelming confusion. They may have rapid shifts from one intense affect to another.

Although brief, the level of impairment may be severe, and supervision may be required to ensure that nutritional and hygienic needs are met and that the individual is protected from the consequences of poor judgment, cognitive impairment, or acting on the basis of delusions.

B. Signs and Symptoms

Hallucinations: Hallucinations are sensory perceptions of things that aren't actually present, such as hearing voices, seeing things that aren't there, or feeling sensations on your skin even though nothing is touching your body. Delusions: These are false beliefs that the person refuses to give up, even in the face of contradictory facts.

Other symptoms of brief psychotic disorder include: Disorganized thinking Speech or language that doesn't make sense Unusual behavior and dress Problems with memory Disorientation or confusion Changes in eating or sleeping habits, energy level, or weight Inability to make decisions

Brief psychotic disorder is uncommon. It generally first occurs in early adulthood (20s and 30s), and is more common in women than in men. People who have a personality disorder -- such as antisocial personality disorder or paranoid personality disorder -- are more prone to developing brief psychotic disorder.

C. Different Perspectives

Psychodynamic Perspectives - it suggests that the psychotic symptoms occur because of inadequate coping mechanisms, as a defense against prohibited fantasy, or as an escape from a specific psychological situation or an overwhelming stressful circumstance.

Psychosocial perspective - culture shapes the form a psychotic reaction may take, culture also determines what is not to be considered psychotic. Behaviors that in one culture would be thought of as bizarre or psychotic, may be acceptable in another.

Neurobiological Perspective - In some susceptible women, dramatic hormonal changes in childbirth and shortly afterward can result in a form of brief psychotic disorder often referred to as postpartum psychosis .

D. Diagnostic Criteria
of one (or more) of the following symptoms: Delusions Hallucinations Disorganized speech (e.g., frequent derailment or incoherence) Grossly disorganized or catatonic behavior Note: Do not include a symptom if it is a culturally sanctioned response pattern.
Presence

 Duration

of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. The disturbance is not better accounted for by a mood disorder with psychotic features, schizoaffective disorder, or schizophrenia and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify if: With marked stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the persons culture.

Without marked stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the persons culture. With postpartum onset: if onset within 4 weeks postpartum.

295.70
SCHIZOAFFECTIV E DISORDER

A. Essential Features
An interrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia. During the same period of illness, there have been delusions of hallucinations for at least 2 weeks in the absence of

Symptoms that meet criteria for mood episode are present for a substantial portion of the total duration of the active and residual periods of illness. The disturbance is not due to the direct physiological effects of substance (e.g. a drug abuse, a medication) or a general medication condition.

For other individual, this may last for years or decades. Complete recovery is characterized when one no longer demonstrates any significant symptoms of the disorder within a significant interval of time. Usually begins in the late teen years or early adulthood approximately between 16-3- years old. Slightly more usual in women than in men, and is rare in children.

B. Signs and Symptoms

Positive Symptoms Delusions Hallucinations Disorganized speech (e.g. frequent derailment or incoherence) Grossly disorganized or catatonic behavior

Negative Symptoms

Affective flattening (diminished or absence of emotional expressiveness) Alogia (lack or decline in speech) Avolition (lack or drop in motivation) Anhedonia (inability to experience pleasurable emotions from normally pleasurable life events such as eating, exercise, social interaction, or sexual activities) The Major Depressive Episode must include Criterion A1: depressed mood.

C. Different Perspectives
Although the exact cause of schizoaffective disorder is unknown, it is believes that factors in terms of genetic, biochemical and environmental aspects are responsible. These different said factors may have interacted with the existing predisposition in ones genes in ways that can either increase or decrease ones risk to develop such disorder.

Biological Perspective

Genetics (Heredity) Schizoaffective disorder may be passed from parents to children and from generation to generation. Individuals who have close relative, and/or ancestors who had history of such disorder have higher risk in developing this disorder compared to those who do not have history of such disorder in their lineage. Having relatives with schizophrenia and/or mood disorder may increase ones risk of having Schizoaffective disorder.

Brain Chemistry Imbalance of certain chemicals in the brain may be present in schizophrenia and mood disorder patients. These neurotransmitters are substances that are responsible in sending messages to and from the brain through the neurons or brain cells. It is believed that dopamine and serotonin are the neurotransmitters that are responsible in this disorder. Any imbalance in these chemicals can interfere with the transmission of messages and thus may

Neurodevelopmental Factors Schizoaffective disorder is believed to be caused by variations or delay in the way ones brain develops during childhood.

Psychosocial Perspective

Environmental Factors There are evidences that show that certain factors from the environment cause this disorder. These factors may be viral infection, poor social interaction or highly stressful situations. These factors may serve as trigger for schizoaffective disorder to manifest in people who may already have inherited disposition in such disorder.

 This

perspective is the least possible reason among the different perspectives in Abnormal Psychology. Experts believe that schizophrenia particularly the schizoaffective disorder are primarily caused by genes or heredity that may instantly manifest at a particular age or may be triggered by experiences explained earlier.

D. Diagnostic Criteria
Specify Type: Bipolar Type: If the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episode) Depressive Type: If the disturbance only includes Major Depressive Episodes.

297.30
SHARED PSYCHOTIC DISORDER

the folly of two is a delusion that develops in an individual who is involved in a close relationship with another person who already has a Psychotic Disorder with prominent delusions. Quite a little is known about shared psychotic disorder or folie a deux which literally means a madness shared by two, a condition in which an individual develops delusions simply as a result of a close relationship with a delusional individual.

The content and nature of the delusion originated with the partner and can range from the relatively bizarre, such as believing enemies are sending harmful gamma rays to your house or to the fairly ordinary, such as believing you are about to receive a major promotion despite evidence to the contrary. The delusions are induced in the secondary case and usually disappear when the people are separated. Aside from the delusions, the thoughts and behavior of people with shared psychotic disorder are usually fairly normal.

Types of Shared Psychotic Disorder (Gralnick, 1942)

* folie impose or Subtype A. The delusions of a person with psychosis are transferred to a person who is mentally sound. Both persons are intimately associated, and the delusions of the recipient disappear after separation. The mental status exam of both affected individuals would be significant for delusion thinking, lack of judgment and insight, poor attention and concentration, and affect may or may not be affected. Both individuals would be perseverative and sometimes preoccupied with limited relatedness.

* folie simultane or Subtype B. The simultaneous appearance of an identical psychosis occurs in 2 individuals who are both intimately associated and morbidly predisposed. The mental status exam of the affected individuals would be consistent with paranoia, lack of insight, disorganized thought processes in extreme cases, lack of relatedness.

* folie communiqu or Subtype C. The recipient develops psychosis after a long period of resistance and maintains the symptoms even after separation. The mental status exam may be consistent with hypervigilance, obsessive thinking, brooding, rumination, anxiety, and lack of reasoning.

* foile induite or Subtype D. New delusions are adopted by an individual with psychosis who is under the influence of another individual with psychosis. The mental status exam would be similar to one of a psychotic patient, namely paranoia; lack of reasoning, judgment, and insight; and poor relatedness. Limited eye contact, bizarre mannerisms, and magical thinking may be apparent on assessment.

B. Different Perspectives
Psychosocial Perspective There are several variables which have great influence on the creation of shared psychotic disorder. These variables include family isolation, closeness of the relationship to the person with the primary diagnosis, the length of time the relationship has existed, and the existence of a dominantsubmissive factor within the relationship. The submissive partner in the relationship may be predisposed to have a mental disorder. Often the submissive partner meets the criteria for dependent personality disorder.

Factors arise because of unhealthy or interrupted ego development during the early stages of life. As Freud suggested with his theories on the Oedipus and Electra complexes, children develop attraction to the opposite-sex parent, developing a greater sense of self by comparing and resisting identification with their same-sex male or female parent. If the relationship between parent and child is filled with jealousy, rejection, or anger, or if the relationship becomes more sexual than that of a healthy parent-child relationship, symptoms of folie a deux generally express themselves.

D. Diagnostic Criteria

A. A delusion develops in the context of a close relationship with another person who already has an established delusion. B. The delusion is similar in content to that of the person who already has the established delusion. C. Other psychotic disorders are ruled out.

297.1 DELUSIONAL DISORDER

A. Essential Features

* The essential feature of Delusional Disorder is the presence of nonbizarre delusions that persist for at least a month.

* They are often long-standing, sometimes persisting over several years.

* Individuals with delusional disorder tend not to have flat affect, anhedonia or other negative symptoms of schizophrenia; importantly, however, they may become socially isolated because they are suspicious of others.

* Psychosocial functioning is not markedly impaired, and behavior is neither obviously odd nor bizarre. * Common characteristic of individuals with Delusional Disorder is the apparent normality of their behavior and appearance when their delusional ideas are not being discussed or acted on. [Therefore people can lead relatively normal lives and better than those with schizophrenia]

* Delusions differ from the more bizarre types often found in people with schizophrenia because in delusional disorder the imagined events could be happening but are not (mistakenly believing you are being followed); in schizophrenia, however, the imagined events are not possible (believing your brain waves broadcast your thoughts to other people around the world).

B. Different Perspectives

BIOLOGICAL PERSPECTIVE (1) The neurological conditions most commonly associated with delusions affect the limbic system and the basal ganglia. Patients whose delusions are caused by neurological diseases and show no intellectual impairment tend to have complex delusions similar to those in patients with delusional disorder. Conversely, patients with neurological disorder with intellectual impairments often have simple delusions unlike those in patients with delusional disorder. Thus, delusional disorder may involve the limbic system or basal ganglia in patients who have intact cerebral cortical functioning.

(2) Catalano et al (1993) studying genotype of schizophrenia, normal and DD subjects found that involvement of genetic variation in the Dopamine D4 receptor gene confirmed susceptibility to DD.

COGNITIVE PERSPECTIVE Dysfunctional Cognitive Processing The fields of cognitive and experimental psychology suggest that persons with delusions selectively attend to available information. They make conclusions based on insufficient information, attribute negative events to external personal causes, and have difficulty in envisaging others intentions and motivations.

Two neuropsychological models proposed for schizophrenia may also have some validity in delusional disorder. A cognitive bias model (CBM) proposes that paranoia is a defense against thoughts that threaten the idealized self, to protect a fragile self-esteem. Positive events are attributed to the self whereas negative events are ascribed to the external environment. In contrast, the cognitive deficit model (CDM) focuses on cognitive impairments and distortions of threat evaluating mechanisms as the cause for delusion formation.

PSYCHODYNAMIC PERSPECTIVE Defense Mechanism They use reaction formation as a defense against aggression, dependence needs, and feelings of affection and transform the need for dependence into loyal independence. Patients use denial to avoid awareness of painful reality Consumed with anger and hostility and unable to face responsibility for the rage, they project their resentment and anger onto others and use projection to protect themselves from recognizing unacceptable impulses in themselves.

Norman Cameron described seven situations that favor the development of delusional disorders: (1) an increased expectation of receiving sadistic treatment (2) situations that increase distrust and suspicion, (3) social isolation, (4) situations that increase envy and jealousy, (5) situations that lower self-esteem, (6) situations that cause persons to see their own defects in others and (7) situations that increase the potential rumination over probable meanings and motivations. When frustration from any combination of these conditions exceeds the tolerable limit, persons become withdrawn and anxious, they realize that something is wrong, seek an explanation for the

Clinical observations indicate that many, if not all, paranoid patients experience a lack of trust in relationship. This hypothesis relates the distrust to a consistently hostile family environment, often with an overcontroling mother and a distant or sadistic father. Delusional disorder can also be triggered by stress.

C. Diagnostic Criteria

A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration. B. Criterion A for Schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme. C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.

D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify type (the following types are assigned based on the predominant delusional theme): Erotomanic Type: delusions that another person, usually of higher status, is in love with the individual Grandiose Type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.

Jealous Type: delusions that the individual's sexual partner is unfaithful. Persecutory Type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way. Somatic Type: delusions that the person has some physical defect or general medical condition. Mixed Type: delusions characteristic of more than one of the above types but no one theme predominates. Unspecified Type

293.81
PD Due to GENERAL MEDICAL CONDITION

A. Essential Features

The essential features of Psychotic Disorder Due to a General Medical Condition are prominent hallucinations or delusions that are judged to be due to the direct physiological effects of a general medical condition. There must be evidence from the history, physical examination, or laboratory findings that the delusions or hallucinations are the direct physiological consequence of a general medical condition. The psychotic disturbance is not better accounted for by another mental disorder (e.g., the symptoms are not a psychologically mediated response to a severe general medical condition, in which case a diagnosis of Brief Psychotic Disorder, With Marked Stressor, would be appropriate). The diagnosis is not made if the disturbance occurs only during the course of a delirium.

B. Signs and Symptoms

Hallucinations (293.81)
Can

occur in any sensory modality (i.e. visual, olfactory, gustatory, tactile, or auditory). A hallucinating patient knows no significant changes in cognitive functions

Delusion (293.82)
May

be expressed in a variety of themes including somatic, grandiose, religious, and persecutory Associations with a particular general medical condition is less specific than hallucinations Mild cognitive impairment may be observed

C. Different Perspectives

Biological Perspective
Olfactory

hallucinations are highly suggestive of temporal lobe epilepsy Religious delusions are associated with temporal lobe epilepsy Right parietal brain lesions develop contralateral neglect syndrome in which they may disown parts of their body to a delusional extent

D. Diagnostic Criteria

Prominent hallucinations or delusions B. There is evidence from the history, physical examination or laboratory findings that the delusions or hallucinations are direct physiological consequence of a general medical condition C. Disturbance is not better accounted for by another mental disorder D. The disturbance does not occur exclusively during the course of a delirium

293.81

PD Due to GENERAL MEDICAL CONDITION

A. Essential Features

Signs and Symptoms

Hallucinations (293.81) Can occur in any sensory modality (i.e. visual, olfactory, gustatory, tactile, or auditory). A hallucinating patient knows no significant changes in cognitive functions Delusion (293.82) May be expressed in a variety of themes including somatic, grandiose, religious, and persecutory Associations of delusion with a particular general medical condition is less specific than hallucinations Mild cognitive impairment may be observed

A. Essential Features

Development Psychotic Disorder may be a single transient state or it may be recurrent, cycling with exacerbations and remissions of the underlying general medical condition Although treatment of the underlying general medical condition often results in a resolution of the psychotic symptoms, this is not always the case, and psychotic symptoms may persist long after the causative medical event.

A. Essential Features

Prevalence
Prevalence rates for Psychotic Disorder Due to a General Medical Condition are difficult to estimate given the wide variety of underlying medical etiologies. Research does suggest that the syndrome is underdiagnosed in the general medical setting. Psychotic symptoms may be present in as many as 20% of individuals presenting with untreated endocrine disorders, 15% of those with systemic lupus erythematosus, and up to 40% or more of individuals with temporal lobe epilepsy.

A. Essential Features

In recording the diagnosis of Psychotic Disorder due to General Medical Condition, the clinician must first establish the presence of a general medical condition. There must be evidence that prominent hallucinations or delusions are the direct physiological consequence of a general medical condition. Psychotic Disorder due to a General Medical Condition is generally not diagnosed if the individual maintains reality testing for the hallucination and appreciates that the perceptual experiences result

B. Perspectives

Neurobiological Perspective A variety of neurological conditions may cause psychotic symptoms (e.g. neoplasms, cerebrovascular disease, Huntington's disease, multiple sclerosis, epilepsy, auditory or visual nerve injury or impairment, deafness, migraine or central nervous system infections). Olfactory hallucinations are highly suggestive of temporal lobe epilepsy

B. Perspectives
Religious

delusions are also associated with temporal lobe epilepsy Right parietal brain lesions develop contralateral neglect syndrome in which they may disown parts of their body to a delusional extent Those neurological conditions that involve subcortical structures or the temporal lobe are more commonly associated with delusions.

C. Diagnostic Criteria
A. Prominent hallucinations or delusions B. There is evidence from the history, physical examination or laboratory findings that the delusions or hallucinations are direct physiological consequence of a general medical condition C. Disturbance is not better accounted for by another mental disorder D. The disturbance doe not occur exclusively during the course of a delirium

SubstanceInduced Psychotic Disorder

A. Essential Features

Can occur when people ingest toxic substances by accident, take too much of a prescribed medicine or miscalculation on the doctors part; or overdose of recreational drugs.

Should only be made when psychotic symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome When the symptoms are sufficiently severe to warrant independent clinical attention

Arise only in association with intoxication or withdrawal states but can persist for weeks Psychotic symptoms may continue as long as the substance use continues Presence of features that are atypical of a primary Psychotic Disorder.

In absence of delirium, hallucinations are usually auditory (voices). Persecutory delusions, formication (hallucinations of bugs or vermin crawling in or under the skin) Marked anxiety, emotional lability, depersonalization, and subsequent amnesia for the episode can occur

Common drugs are alcohol, amphetamine, Cannabis, Cocaine, Hallucinogen, Inhalant, Opioid, Phencyclidine, Sedative, Hypnotic, and Anxiolytic.

Common over-the-counter and doctor prescribed medicines are anaesthetics, analgesics, anticholinergic agents, anticonvulsants, antihistamines, antihypertensive, cardiovascular medications, antiparkinsonian medications, antidepressants, etc.

Common environmental toxins are anticholinesterase, organophosphate insecticides, nerve gases, carbon monoxide, carbon dioxide, and volatile substances like fuel or paint.

B. Different Perspectives

Biological Perspective: Drugs interfere with the neurotransmitters thus inducing imbalanced psychological activities
High

level of Dopamine is significantly correlated to Schizophrenia.

Psychodynamic Perspective
Drugs (object) serve as the means through which the aim (reducing anxiety) is satisfied. Isolation of Affect- addicts will disregard everything. Nothing else will matter but the drug.

Behavioral Perspective

Drug Addiction is a learned behavior. Positive reinforcement- strengthening of addiction due to presence of pleasurable feelings Negative reinforcement- strengthening of addiction due to decreased levels of anxiety during intoxication Vicious cycle theory

Cognitive Perspective
Cognitive distortion of psychological dependence. Psychological dependence is the thinking that the drug is needed to continue a feeling of well-being.

A. Prominent hallucinations or delusions. Note: Do not include hallucinations if the person has insight that they are substance induced. B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):

(1) the symptoms in Criterion A developed during, or within a month, of Substance Intoxication or Withdrawal. (2) medication use is etiologically related to the disturbance

C. The disturbance is not better accounted for by a Psychotic Disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not substance induced might include the following:

Symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (eg, about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use;

Or there is other evidence that suggests the existence of an independent non-substance-induced Psychotic Disorder (eg. A history of recurrent non-substance-related episodes).

D. The disturbance does not occur exclusively during the course of delirium.

One of the ff subtypes may be used to indicate predominant symptom presentation. With Delusions.(292.11; 291.5 for alcohol) With Hallucinations. (292.12; 291.3 for alcohol) If both are present, code whichever is predominant.

The context of the development of the psychotic symptoms may be indicated by using one of the specifiers : With Onset during Intoxication. With Onset during Withdrawal.

298.9
Psychotic Disorder Not Otherwise Specified

This category includes psychotic symptomatology (ie., delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate information to make specific diagnosis or about which there is contradictory information, or disorders with psychotic symptoms that do not meet the criteria for any specific Psychotic Disorder.


1.

2.

3.

Examples are: Psychotic symptoms that have lasted for less than 1 month but have not yet remitted, so that the criteria for Brief Psychotic are not met Persistent auditory hallucinations in the absence of any other features Situations in which the clinician has conducted that a Psychotic Disorder is present, but is unable to determine whether it is primary, due to general medical conditions, or substance induced.

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