Schizophrenia

Spectrum and Other

Psychotic Disorders
Seminar 4
Introductory Textbook of Psychiatry, 6th edition
Donald W.Black, M.D., Nancy C.andreasen, M.D., Ph.D.
 DSM-5 Schizophrenia Spectrum
Schizotypal personality disorder
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Schizoaffective Disorder
-----------------------------------------------
Substance and medication-related psychotic
disorders
Psychotic disorder due to another medical
condition
 Psychotic disorders are heterogeneous, and the severity of
symptoms can predict important aspects of the illness, such
as the degree of cognitive or neurobiological deficits.

Many individuals with psychotic disorders have impairments

in a range of cognitive domains that predict functional
status. Clinical neuropsychological assessment can help
guide diagnosis and treatment, but brief assessments
without formal neuropsychological assessment can provide
useful information that can be sufficient for diagnostic
purposes. Formal neuropsychological testing, when
conducted, should be administered and scored by personnel
trained in the use of testing instruments. If a formal
neuropsychological assessment is not conducted, the
clinician should use the best available information to make a
judgment.
 Delusional Disorder

Presence of well-systematized delusions

accompanied by affect appropriate to the
delusion occurring in the presence of a relatively
well-preserved personality

The core feature of delusional disorder is the

presence of delusion in the absence of obviously
odd or bizarre behavior
 Diagnostic Criteria
A. The presence of one (or more) delusions with a duration of 1 month or
longer.

B. Criterion A for schizophrenia has never been met.

Note: Hallucinations, if present, are not prominent and are related to the
delusional theme (e.g., the sensation of being infested with insects associated
with delusions of infestation).

C. Apart from the impact of the delusion(s) or its ramifications, functioning is not
markedly impaired, and behavior is not obviously bizarre or odd.

D. If manic or major depressive episodes have occurred, these have been brief
relative to the duration of the delusional periods.

E. The disturbance is not attributable to the physiological effects of a substance

or another medical condition and is not better explained by another mental
disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.
 Specifiers:
Erotomanic type: (de Clerambaults syndrome): This subtype applies when the central theme of the delusion is
that
another person is in love with the individual.

Grandiose type: This subtype applies when the central theme of the delusion is the
conviction of having some great (but unrecognized) talent or insight or having made
some important discovery.

Jealous type: This subtype applies when the central theme of the individuals delusion
is that his or her spouse or lover is unfaithful.

Persecutory type: This subtype applies when the central theme of the delusion involves
the individuals belief that he or she is being conspired against, cheated, spied
on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in
the pursuit of long-term goals.

Somatic type: This subtype applies when the central theme of the delusion involves
bodily functions or sensations.

With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not
understandable, and not derived from ordinary life experiences (e.g. an individuals belief that a
stranger has removed his or her internal organs and replaced them with someone elses organs without
leaving any wounds or scars)
 Course specifiers
The following course specifiers are only to be used after a 1 -year duration of the disorder:

First episode, currently in acute episode: First manifestation of the disorder meeting
the defining diagnostic symptom and time criteria. An acute episode is a time period
in which the symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a time period during
which an improvement after a previous episode is maintained and in which the defining
criteria of the disorder are only partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a
previous episode during which no disorder-specific symptoms are present.

Multiple episodes, currently in acute episode

Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission

Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subthreshold symptom periods being
very brief relative to the overall course.

Unspecified
 Epidemiology/course
Prevalence 0.2% in the general population, is
relatively rare

The persecutory type is most common

No Gender differences in frequencies

Middle to late life adult disorder

Chronic for most, but people are generally

employed and self-supporting
 Clinical Findings
Socially isolated and chronically suspicious

Angry and hostile emotions leading to violent

outbursts

Overtalkative and circumstantial, particularly

when discussing their delusions

End up as lawyers clients rather that

psychiatrists patients
 Differential Diagnosis
Psychotic mood disorder mood symptoms are
absent, develop after psychotic symptoms or are
relatively shorter than psychosis

Schizophrenia disorganized speech, catatonic

behavior and negative symptoms are absent

Paranoid Personality disorder persons are

suspicious and hypervigilant, but not delusional

Dysmorphic disorder their somatic sensations

(misshapen, disfigured ) does not involve bodily functions
or sensations
 Clinical Management
Response to antipsychotics is often poor they help
relieve agitation and anxiety, but core delusion
remains often intact

Treatment recommendations are based on clinical

observations and not careful research

Any of the antipsychotics may be used:

High potency conventional Haloperidol 5-10mg/day
Second-generation Risperidone 2-6 mg/day
Monohypochondriacal paranoia- Pimozide 4-6mg/day
 Clinical Management
Selective Serotonin Reuptake Inhibitors (SSRI)
Fluoxetine, Paroxetine

To develop a trusting relationship with patient

Tact and skills are necessary to persuade patient to

accept the treatment Clinician must neither
condemn nor collude in delusions. Point out how
delusions interfere with patients functioning

Group therapy is not recommended

 Brief psychotic Disorder
Psychotic symptoms last at least 1 day but
no more than 1 month, with gradual recovery

Symptoms are similar to those seen in Schizophrenia :

Hallucinations
Delusions
Disorganized Speech
Glossy disorganized behavior
 Subtypes/Epidemiology
1. With marked stressor
2. Without marked stressor
3. With postpartum onset (during pregnancy or within 4
weeks after delivery. Resolves in 2-3 month)
4. With catatonia

Prevalence - 9% of new-onset psychosis

More common in women, in low-income groups, in

individuals with personality disorders
 Clinical management

No specific treatment

Hospitalization may be necessary

Antypsychotics may be helpful

Supportive psychotherapy after recovery

 Schizophreniform Disorder
When symptoms of schizophrenia last less then
6 month, at least 1 month

After 6 month diagnosis of Schizophrenia is

given, even if only residual symptoms (e.g.
blurred affect) remains

The main use is to guard against premature

diagnosis of Schizophrenia
 Schizoaffective Disorder

The term Schizoaffective was first used by Jacob

Kasanin in 1933 to describe a small group of
severely ill patients who had a mixture of
psychotic and mood symptoms

Two subtypes : Depressive and Bipolar

Prevalence is less then 1% and occurs more often

in woman
 Diagnostic Criteria
A. An uninterrupted period of illness during which there is a major mood
episode (major depressive or manic) concurrent with Criterion A of
schizophrenia.
Note: The major depressive episode must include Criterion A1 : Depressed
mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major
mood episode (depressive or manic) during the lifetime duration of the
illness.
C. Symptoms that meet criteria for a major mood episode are present for
the majority of the total duration of the active and residual portions of the
illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition.
Bipolar type: This subtype applies if a manic episode is part of the
presentation.
Major depressive episodes may also occur.
Depressive type: This subtype applies if only major depressive episodes
are part of the presentation.
Specify if with Catatonia
 Psychotic symptoms must be present for 2 weeks
or more in the absence of prominent mood
symptoms

Mood symptoms must be present for a majority of

the total duration of the illness

Psychotic symptoms may be mood congruent or

mood incongruent

Mood and psychotic symptoms may present

together or in an alternating fashion
 Differential Diagnosis
Schizophrenia mood symptoms are present in
minority of the total duration of the illness

Mood disorders psychotic symptoms generally

occur in the presence of mania or depression

Drugs and medical conditions must be excluded

as a cause use medical history, physical
examination, laboratory tests
 Course
Variable but represents a middle ground between
schizophrenia and mood disorders

A worse outcome is associated with:

Poor premorbid adjustment
Insidious onset
Lack of a precipitation stressor
Predominance of psychotic symptoms
Early onset
Unremitting course
Family history of schizophrenia
 Clinical management
Target both mood and psychotic symptoms
First line treatment - Second generation
antipsychotics
Paliperidone has been approved by FDA
Mood stabilizers (lithium, valproate) or
antidepressants may be beneficial to add

Electroconvulsive Therapy (ECT) for patients

who do not respond on medications, although
medications are typically reinstituted for long-
term maintenance
 Questions for Assessment

How does delusional disorder differ from

schizophrenia?
What are the subtypes of delusional disorder?
Describe brief psychotic disorder.
How does schizoaffective disorder differ
diagnostically from both schizophrenia and
psychotic mood disorders?
 Tests
1. Which symptom is common for Schizophrenia Spectrum
Disorders :

1. Delusions
2. Mania
3. Obsessions
4. Anxiety

2. Which disorder does not represent Schizophrenia Spectrum :

1. Brief psychotic disorder

2. Delusional disorder
3. Schizophreniform disorder
4. Bipolar disorder
3. Personality is preserved in the course of :

1. Schizoaffective disorder
2. Schizophrenia
3. Delusional disorder
4. Schizophreniform disorder

4. Which symptom excludes diagnosis of delusional disorder:

1. Persecutory delusion
2. Hallucinations
3. Flattering Affect
4. Erotomanic delusion
5. Which is not true for delusional disorder:

1. Socially isolated and chronically suspicious

2. Angry and hostile emotions leading to violent outbursts
3. Represents a middle ground between schizophrenia and mood disorders
4. End up as lawyers clients rather that psychiatrists patients

6. When symptoms of schizophrenia last less then 6 month and more than 1 month the person is
diagnosed with:

1. Brief psychotic disorder

2. Obsessive-compulsive disorder
3. Schizophreniform disorder
4. Schizoaffective disorder

7. What is the first line treatment of Schizoaffective disorder

1. Electroconvulsive therapy
2. Antidepressants
3. Mood stabilizers
4. Second generation antipsychotics
8. Postpartum onset psychosis is subtype of :

1. Schizophrenia
2. Schizoaffective disorder
3. Delusional disorder
4. Brief psychotic disorder

9. Psychotic symptoms are present for more then 2 weeks in the absence of mood symptoms, though
mood symptoms represent a majority of the total duration of the illness. Name the diagnosis:

1. Schizophrenia
2. Major depressive disorder
3. Mania
4. Schizoaffective disorder

10. Which statement describes best the main difference of mood disorders from schizoaffective
disorder :

1. Mood symptoms are present in minority of the total duration of the illness
2. Psychotic symptoms generally occur in the presence of mania or depression
3. Persons are suspicious and hypervigilant, but not delusional
4. Response to medications is often poor
A 22-year-old single man is referred to you for a 1-year history of
strange behavior characterized by talking to the television, accusing
local police of bugging his room, and carrying on conversations with
himself. His mother describes a 3-year history of progressive
withdrawal from social activities, and reports the patient dropped out
of college and since has been living in his room at home. Attempts
to hold a job as a busboy at a local restaurant have abruptly ended
after disputes with the employers.

1. What is the prevalence of this patients likely illness in the general

population?

(A) 0.1%
(B) 1%
(C) 2%
(D) 3%
(E) 5%
(B) The patients 3- to 4-year history of bizarre
behavior, delusions, and decline in social
functioning strongly suggest that he has
schizophrenia. The prevalence of schizophrenia in
the general population is approximately 1%.
Schizophrenia is found in all societies and
geographical areas around the world, and
its prevalence is roughly equal in males and
females.
The patients mother informs you that he has
an identical twin brother. What is the likely
chance of the patients twin also having the
same illness?

(A) 1%
(B) 10%
(C) 20%
(D) 50%
(E) 100%
(D) In twin studies, schizophrenias monozygotic
concordance is 40% to 50%, suggesting
that there is a strong genetic component to the
illness. The prevalence of schizophrenia in the
following populations is: 10% to 15% in the
nontwin sibling of a patient with schizophrenia,
12% in the child of one parent with schizophrenia,
and 40% in the child of two parents
with schizophrenia.
A 40-year-old man with schizophrenia comes for his regular outpatient
medication management appointments. He reports that over the last
week his intestines and heart have been removed. He has
subsequently withdrawn and been staying in his basement apartment,
avoiding friends and family members. When asked about his lack of
getting out in the world, he responds, What world? There is no
world!

3. Which of the following terms best describes

this symptom?

(A) Capgras syndrome

(B) Cotard syndrome
(C) Folie deux
(D) Fregoli delusion
(E) Major depressive disorder
(B) Cotard syndrome describes nihilistic delusional content; in addition to lost possessions,
patients may feel they have lost blood, heart, intestines, as well as believe that the world beyond
them has been reduced to nothingness. This psychotic/ delusional theme can be seen in many
psychotic illnesses.

Capgras syndrome is a delusion of doubles characterized by the belief that people have been
replaced by identically appearing imposters.

Folie deux, or shared psychotic disorder, is when a similar delusion is aroused in one person by
the close influence of another; both individuals are usually closely associated for a prolonged
period of time.

The Fregoli delusion is a variation of the delusion of doubles, and is the belief that familiar
people assume the guise of strangers. While major depressive disorder can manifest with
psychotic features, the prominence of psychosis with bizarre (not possible) delusions and without
clear depressed mood makes this diagnosis less likely. Further, though nihilistic themes and
negativism can be observed in depression, the delusions are usually nonbizarre (potentially
feasible).
Upon returning for a follow-up visit 15 days
later, the patient now claims that cyborg
alien robots that look identical to his parents
have recently replaced his mother and father.
Which of the following terms best describes
this symptom?

(A) Capgras syndrome

(B) Cotard syndrome
(C) Delusional disorder
(D) Folie deux
(E) Fregoli delusion
(A) The belief that people have been replaced
by imposters is the hallmark of Capgras
syndrome. Delusional disorder is characterized
by the presence of (usually) nonbizarre
delusions.
The family of a 26-year-old patient with schizophrenia brings him in for
follow-up. He was initially diagnosed at age 25 after a psychotic break
that, in retrospect, followed a protracted course of increasing isolation
and amotivation. Despite difficulties, he was able to graduate from
college and hold a full-time job by age 23. He reports intermittent
hallucinations, but has been able to maintain independent living and
part-time employment. On examination, he is a disheveled man who
articulates a multitude of delusional beliefs with a sophisticated
vocabulary. Which of the following characteristics in this patient is
most strongly associated with a better overall prognosis?

(A) Age at presentation

(B) Gender of patient
(C) Insidious symptom onset
(D) Predominantly positive symptoms
(E) Premorbid functioning
(E) Good premorbid functioning portends a better
prognosis for this patient. Other features of
schizophrenia that predict a better prognosis include
later age at presentation, female gender, acute and
rapid onset of symptoms (as opposed to insidious
onset), and the presence of mood symptoms. While
predominantly positive symptoms also predict a more
favorable prognosis, this patient has significant
negative symptoms, as evidenced by his isolation and
amotivation.
A 49-year-old bank teller with no known psychiatric history is
referred to your office by her internist for an evaluation. For
the past 2 months, she has been increasingly convinced that a
well-known music star is in love with her and that they have
had an ongoing affair. She is well-groomed, and there is no
evidence of thought disorder or hallucinations. She has
been functioning well at work and in other social
relationships. Which of the following is the most likely
diagnosis?

(A) Brief psychotic disorder

(B) Delusional disorder
(C) Paranoid personality disorder
(D) Schizophrenia
(E) Schizophreniform disorder
(B) This womans presentation is most consistent with a
delusional disorder. She has no other psychotic
symptoms, her functioning is still good, and the delusion
is isolated to one specific belief. In addition, this patients
delusion is nonbizarre (i.e., could possibly occur). While
delusional disorder may consist of a bizarre (could not
occur) delusion, it is not as common. She does not exhibit
other psychotic symptoms, making brief psychotic
disorder unlikely; further, in brief psychotic disorder,
symptoms must resolve within 1 month whereas hers
have been occurring for at least 2 months. There is no
evidence she has a paranoid personality disorder.
Schizophrenia and schizophreniform disorder are unlikely
since her symptoms are limited to one delusion,
and she has no hallucinations, negative symptoms, nor
impairment in functioning. In addition, the time course is
insufficient for these diagnoses.
 A 54-year-old man with a chronic mental illness
seems to be constantly chewing. He does not wear
dentures. His tongue darts in and out of his mouth,
and he occasionally smacks his lips. He also
grimaces, frowns, and blinks excessively. Which of
the following disorders is most likely in this patient?

a. Tourettes syndrome
b. Akathisia
c. Tardive dyskinesia
d. Parkinsons disease
e. Huntingtons disease
 Tardive dyskinesia (TD) is characterized by
involuntary choreoathetoid movements of the face,
trunk, and extremities. Tardive dyskinesia is
associated with prolonged use of medications that
block dopamine receptors, most commonly
antipsychotic medications. Typical antipsychotic
medications (such as perphenazine) and, in
particular, high-potency drugs carry them highest
risk of TD. Atypical antipsychotics are thought to be
less likely to cause this disorder.
A 19-year-old man is brought to the physician by his parents after he
called them from college, terrified that the Mafia was after him. He reports
that he has eaten nothing for the past six weeks other than canned beans
because they are into everythingI cant be too careful. He is convinced
that the Mafia has put cameras in his dormitory room and that they are
watching his every move. He occasionally hears the voices of two men talking
about him when no one is around. His roommate states that for the past
two months the patient has been increasingly withdrawn and suspicious.
Which of the following is the most likely diagnosis?

a. Delusional disorder
b. Schizoaffective disorder
c. Schizophreniform disorder
d. Schizophrenia
e. PCP intoxication
Schizophreniform disorder and chronic schizophrenia differ only in the duration of the
symptoms and the fact that the impaired social or occupational functioning associated
with chronic schizophrenia is not required to diagnose schizophreniform disorder. As
with schizophrenia, schizophreniform disorder is characterized by the presence of
delusions, hallucinations, disorganized thoughts and speech, and negative symptoms.
The total duration of the illness, including prodromal and residual phases, is at least
one month and less than six months. Approximately one-third of patients diagnosed
with schizophreniform disorder experience a full recovery, while the rest progress to
schizophrenia and schizoaffective disorder.

Depending on the predominance of particular symptoms, four subtypes of

schizophrenia are recognized: paranoid, disorganized, catatonic, and residual. The man
in the question presents with the classic symptoms of paranoid schizophrenia. This
subtype of schizophrenia is characterized by prominent hallucinations and delusional
ideations with a relative preservation of affect and cognitive functions. Delusions are
usually grandiose or persecutory or both, organized around a central coherent theme.
Hallucinations, usually auditory, are frequent and related to the delusional theme.
Anxiety, anger, argumentativeness, and aloofness are
often present. Paranoid schizophrenia tends to develop later in life and is associated
with a better prognosis.
A 36-year-old woman is brought to the psychiatrist by her husband
because for the past eight months she has refused to go out of the house,
believing that the neighbors are trying to harm her. She is afraid that if they
see her they will hurt her, and she finds many small bits of evidence to
support this. This evidence includes the neighbors leaving their garbage cans
out on the street to try to trip her, parking their cars in their driveways so
they can hide behind them and spy on her, and walking by her house to try
to get a look into where she is hiding. She states that her mood is fine and
would be better if they would leave me alone. She denies hearing the
neighbors or anyone else talk to her, but is sure that they are out to cause
her death and mayhem. Which of the following is the most likely diagnosis?

a. Delusional disorder
b. Schizophreniform disorder
c. Schizoaffective disorder
d. Schizophrenia
e. Major depression with psychotic features
The main feature of delusional disorder is the presence of
one or more nonbizarre delusions without deterioration
of psychosocial functioning and in the absence of bizarre
or odd behavior. Auditory and visual hallucinations, if
present, are not prominent and are related to the
delusional theme. Tactile and olfactory hallucinations
may also be present if they are incorporated in the
delusional system (such as feeling insects crawling over
the skin in delusions of infestation). Subtypes of
delusional disorder include erotomanic, grandiose,
jealous, persecutory, and somatic (delusions of being
infested with parasites, of emitting a bad odor, of having
AIDS). Delusional disorder usually manifests in middle or
late adult life and has a fluctuating course with periods of
remissions and relapses.
A 20-year-old woman is brought to the emergency room by
her family because they have been unable to get her to eat or
drink anything for the past two days. The patient, although
awake, is completely unresponsive both vocally and
nonverbally. She actively resists any attempt to be moved.
Her family reports that during the previous seven months she
became increasingly withdrawn, socially isolated, and bizarre,
often speaking to people no one else could see. Which of the
following is the most likely diagnosis?

a. Schizoaffective disorder
b. Delusional disorder
c. Schizophreniform disorder
d. Catatonia
e. PCP intoxication
Catatonic schizophrenia is characterized by marked
psychomotor disturbances including prolonged
immobility, posturing, extreme negativism (the
patient actively resists any attempts made to
change his or her position) or waxy flexibility (the
patient maintains the position in which he or she is
placed), mutism, echolalia, (repetition of words said
by another person), and echopraxia (repetition of
movements made by another person). Periods of
immobility and mutism can alternate with periods
of extreme agitation (catatonic excitement).
A 21-year-old man is brought to the emergency room by his parents
after he attempted to stab himself with a knife. They note that during the
past eight months the patient has become increasingly isolated, disheveled,
and bizarre. For the last three days he has locked himself in his room,
apparently afraid that someone will hurt him. When questioned, the
patient states that he needs to cut his heart out because a voice is telling
him that is the only way he will end up in heaven. What is the percentage
of patients with this diagnosis who ultimately complete such suicide
attempts?

a. 1%
b. 5%
c. 10%
d. 20%
e. 30%
Suicide is a significant risk factor for
schizophrenic patients, and it has been
calculated that approximately 9 to
13% of these patients commit suicide as a result
of despair and depression
or in response to command hallucinations or
persecutory delusions.
A 47-year-old woman is brought to the emergency room after she
jumped off an overpass in a suicide attempt. In the emergency room she
states that she wanted to kill herself because the devil had been tormenting
her for many years. After stabilization of her fractures, she is admitted to
the psychiatric unit, where she is treated with risperidone and sertraline.
After two weeks she is no longer suicidal and her mood is euthymic. However,
she still believes that the devil is recruiting people to try to persecute
her. In the past 10 years, the patient has had three similar episodes prior to
this one. Throughout this time, she has never stopped believing that the
devil is persecuting her. Which of the following is the most appropriate
diagnosis for this patient?

a. Delusional disorder
b. Schizoaffective disorder
c. Schizophrenia, paranoid type
d. Schizophreniform disorder
e. Major depression with psychotic features
Schizoaffective disorder is diagnosed when the required criteria for
schizophrenia are met (delusions, hallucination, disorganized speech or
behavior, and/or negative symptoms; duration of the disturbance,
including prodromal and residual period, of at least six months with at
least one month of active symptoms) and the patient experiences at
some point in the course of the illness a major depressive episode or a
manic episode. The woman in this question meets all these criteria.
She has continuing psychotic symptomatology, interspersed with
episodes of a major mood disorder. Notably, she has never had the
mood symptoms without the psychotic symptoms, ruling out major
depression with psychosis as the diagnosis. Delusional disorder is not
accompanied by decline in functions or significant affective symptoms.
Individuals with schizoid personality disorder do not experience
psychotic symptoms. Bipolar disorder is differentiated from
schizoaffective disorder by the absence of periods of psychosis
accompanied by prominent affective symptoms.