Title psych-trans-1-1-schizophrenia.pdf ✅

Page 1 of 10 PSYCHIATRY 2 Schizophrenia Spectrum and Other Psychotic Disorders Dr. Los Banos 1.1 June 19, 2014 Bautista, Cruz, Gillera, Janolo, Merilles OUTLINE I. Key Features that Define Psychotic Disorders II. Schizotypal (Personality) Disorder III. Brief Psychotic Disorder IV. Schizophreniform Disorder V. Schizophrenia KEY FEATURES THAT DEFINE PSYCHOTIC DISORDERS  Schizophrenia spectrum and other psychotic disorders o include schizophrenia, other psychotic disorders, and schizotypal (personality) disorder o defined by abnormalities in one or more of the following five domains:  delusions  hallucinations  disorganized thinking (speech)  grossly disorganized or abnormal motor behavior (including catatonia)  negative symptoms DELUSIONS  fixed beliefs that are not amenable to change in light of conflicting evidence  content may include a variety of themes (e.g., persecutory, referential, somatic, religious, grandiose) Persecutory delusions Most common belief that one is going to be harmed, harassed, and so forth by an individual, organization, or other group Referential delusions belief that certain gestures, comments, environmental cues, and so forth are directed at oneself Grandiose delusions when an individual believes that he or she has exceptional abilities, wealth, or fame Erotomanie delusions when an individual believes falsely that another person is in love with him or her Nihilistic delusions involve the conviction that a major catastrophe will occur Somatic delusions preoccupations regarding health and organ function  Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences. o Delusions that express a loss of control over mind or body are generally considered to be bizarre Bizarre delusion Example: the belief that an outside force has removed one‘s internal organs and replaced them with someone else's organs without leaving any wounds or scars THOUGHT WITHDRAWAL: belief that one's thoughts have been "removed" by some outside force THOUGHT INSERTION: alien thoughts have been put into one's mind DELUSIONS OF CONTROL: one's body or actions are being acted on or manipulated by some outside force Nonbizarre delusion Example: the belief that one is under surveillance by the police, despite a lack of convincing evidence  The distinction between a delusion and a strongly held idea is sometimes difficult to make and depends in part on the degree of conviction with which the belief is held despite clear or reasonable contradictory evidence regarding its veracity. HALLUCINATIONS  Perception-like experiences that occur without an external stimulus o vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control  These may occur in any sensory modality, but auditory hallucinations are the most common in schizophrenia o Auditory hallucinations are usually experienced as voices, whether familiar or unfamiliar, which are perceived as distinct from the individual's own thoughts.  The hallucinations must occur in the context of a clear sensorium.  Hypnagogic and Hypnopompic hallucinations are considered to be within the range of normal experience. o HYPNAGOGIC HALLUCINATIONS: those that occur while falling asleep o HYPNOPOMPIC HALLUCINATIONS: those that occur while waking up  Hallucinations may be a normal part of religious experience in certain cultural contexts. DISORGANIZED THINKING/ SPEECH  Disorganized thinking (formal thought disorder) is typically inferred from the individual's speech. Derailment or loose associations The individual may switch from one topic to another Tangentiality Answers to questions may be obliquely related or completely unrelated Incoherence or "word salad" Speech may be so severely disorganized that it is nearly incomprehensible and resembles receptive aphasia in its linguistic disorganization  Because mildly disorganized speech is common and nonspecific, the symptom must be severe enough to substantially impair effective communication. o The severity of the impairment may be difficult to evaluate if the person making the diagnosis comes from a different linguistic background than that of the person being examined.  Less severe disorganized thinking or speech may occur during the prodromal and residual periods of schizophrenia. GROSSLY DISORGANIZED OR ABNORMAL MOTOR BEHAVIOR (INCLUDING CATATONIA)  Grossly disorganized or abnormal motor behavior may manifest itself in a variety of ways, ranging from childlike "silliness" to unpredictable agitation. o Problems may be noted in any form of goal-directed behavior, leading to difficulties in performing activities of daily living.  Catatonic behavior is a marked decrease in reactivity to the environment, ranging from: o NEGATIVISM: resistance to instructions o maintaining a rigid, inappropriate or bizarre posture o MUTISM and STUPOR: complete lack of verbal and motor responses o CATATONIC EXCITEMENT: purposeless and excessive motor activity without obvious cause o Other features: repeated stereotyped movements, staring, grimacing, mutism, and the echoing of speech  Although catatonia has historically been associated with schizophrenia, catatonic symptoms are nonspecific and may occur in other mental disorders (e.g., bipolar or depressive disorders with catatonia) and in medical conditions (catatonic disorder due to another medical condition).
Page 2 of 10 PSYCHIATRY 2 Schizophrenia Spectrum and Other Psychotic Disorders 1.1 June 19, 2014 Bautista, Cruz, Gillera, Janolo, Merilles NEGATIVE SYMPTOMS  Negative symptoms account for a substantial portion of the morbidity associated with schizophrenia but are less prominent in other psychotic disorders.  Two Most Prominent Negative Symptoms in schizophrenia: o Diminished emotional expression  includes reductions in the expression of emotions in the face, eye contact, intonation of speech (prosody), and movements of the hand, head, and face that normally give an emotional emphasis to speech o Avolition  a decrease in motivated self-initiated purposeful activities. The individual may sit for long periods of time and show little interest in participating in work or social activities.  Other negative symptoms: Alogia diminished speech output Anhedonia decreased ability to experience pleasure from positive stimuli or a degradation in the recollection of pleasure previously experienced Asociality apparent lack of interest in social interactions SCHIZOTYPAL (PERSONALITY) DISORDER DELUSIONAL DISORDER 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. Specify whether: Erotomanic type: 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. Jeaious type: This subtype applies when the central theme of the individual‘s 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 individual‘s 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. Mixed type: This subtype applies when no one delusional theme predominates. Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component). Specify if: With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not understandable, and not derived from ordinary life experiences (e.g., an individual‘s belief that a stranger has removed his or her internal organs and replaced them with someone else‘s organs without leaving any wounds or scars). Specify if: The following course specifiers are only to be used after a 1 yr 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 Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (Note: Diagnosis of delusional disorder can be made without using this severity specifier.) SUBTYPES Erotomanic type the central theme of the delusion is that another person is in love with the individual. the person about whom this conviction is held is usually of higher status (e.g., a famous individual or a superior at work) but can be a complete stranger. efforts to contact the object of the delusion are common Grandiose type  the central theme of the delusion is the conviction of having some great talent or insight or of having made some important discovery Less commonly, the individual may have the delusion of having a special relationship with a prominent individual or of being a prominent person (in which case the actual individual may be regarded as an impostor) Grandiose delusions may have a religious content Jealous type the central theme of the delusion is that of an unfaithful partner This belief is arrived at without due cause and is based on incorrect inferences supported by small bits of "evidence" (e.g., disarrayed clothing) The individual with the delusion usually confronts the spouse or lover and attempts to intervene in the imagined infidelity Persecutory type the central theme of the delusion involves the individual's belief of being conspired against, cheated, spied on, followed, poisoned, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals Small slights may be exaggerated and become the focus of a delusional system  The affected individual may engage in repeated attempts to obtain satisfaction by legal or legislative action.  Individuals with persecutory delusions are often resentful and angry and may resort to violence against those they believe are hurting them.
Page 3 of 10 PSYCHIATRY 2 Schizophrenia Spectrum and Other Psychotic Disorders 1.1 June 19, 2014 Bautista, Cruz, Gillera, Janolo, Merilles Somatic type the central theme of the delusion involves bodily functions or sensations Somatic delusions can occur in several forms. Most common is the belief that the individual emits a foul odor; that there is an infestation of insects on or in the skin; that there is an internal parasite; that certain parts of the body are misshapen or ugly; or that parts of the body are not functioning DIAGNOSTIC FEATURES  The essential feature of delusional disorder is the presence of one or more delusions that persist for at least 1 month (Criterion A).  A diagnosis of delusional disorder is not given if the individual has ever had a symptom presentation that met Criterion A for schizophrenia (Criterion B).  Apart from the direct impact of the delusions, impairments in psychosocial functioning may be more circumscribed than those seen in other psychotic disorders such as schizophrenia, and behavior is not obviously bizarre or odd (Criterion C).  If mood episodes occur concurrently with the delusions, the total duration of these mood episodes is brief relative to the total duration of the delusional periods (Criterion D).  The delusions are not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Alzheimer's disease) and are not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder (Criterion E).  In addition to the five symptom domain areas identified in the diagnostic criteria, the assessment of cognition, depression, and mania symptom domains is vital for making critically important distinctions between the various schizophrenia spectrum and other psychotic disorders. ASSOCIATED FEATURES SUPPORTING DIAGNOSIS  Individuals with delusional disorder may be able to factually describe that others view their beliefs as irrational but are unable to accept this themselves (i.e., there may be "factual insight" but no true insight)  Many individuals develop irritable or dysphoric mood, which can usually be understood as a reaction to their delusional beliefs. Anger and violent behavior can occur with persecutory, jealous, and érotomanic types o The individual may engage in htigious or antagonistic behavior (e.g., sending hundreds of letters of protest to the government) o Legal difficulties can occur, particularly in jealous and érotomanic types o Social, marital, or work problems can result from the delusional beliefs of delusional disorder PREVALENCE  The lifetime prevalence of delusional disorder has been estimated at around 0.2% o Most frequent subtype: PERSECUTORY  Delusional disorder, jealous type, is probably more common in males than in females o However, there are no major gender differences in the overall frequency of delusional disorder DEVELOPMENT AND COURSE  On average, global function is generally better than that observed in schizophrenia. Although the diagnosis is generally stable, a proportion of individuals go on to develop schizophrenia.  Delusional disorder has a significant familial relationship with both schizophrenia and schizotypal personality disorder.  Although it can occur in younger age groups, the condition may be more prevalent in older individuals. CULTURE RELATED DIAGNOSTIC ISSUES  An individual's cultural and religious background must be taken into account in evaluating the possible presence of delusional disorder. o The content of delusions also varies across cultural contexts. FUNCTIONAL CONSEQUENCES OF DELUSIONAL DISORDER  The functional impairment is usually more circumscribed than that seen with other psychotic disorders, although in some cases, the impairment may be substantial and include poor occupational functioning and social isolation o When poor psychosocial functioning is present, delusional beliefs themselves often play a significant role.  A 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. DIFFERENTIAL DIAGNOSIS Obsessive- compulsive and Related disorders If an individual with obsessive- compulsive disorder is completely convinced that his or her obsessive- compulsive disorder beliefs are true:  the diagnosis of obsessive- compulsive disorder, with absent insight/delusional beliefs specifier, should be given rather than a diagnosis of delusional disorder.  If an individual with body dysmorphic disorder is completely convinced that his or her body dysmorphic disorder beliefs are true:  the diagnosis of body dysmorphic disorder, with absent insight/delusional beliefs specifier, should be given rather than a diagnosis of delusional disorder Delirium, major neurocognitive disorder, psychotic disorder due to another medical condition, and substance/medica tion-induced psychotic disorder  Individuals with these disorders may present with symptoms that suggest delusional disorder. For example, simple persecutory delusions in the context of major neurocognitive disorder would be diagnosed as major neurocognitive disorder, with behavioral disturbance.  A substance/ medication-induced psychotic disorder cross-sectionally may be identical in symptomatology to delusional disorder but can be distinguished by the chronological relationship of substance use to the onset and remission of the delusional beliefs. Schizophrenia and schizophreniform disorder  Delusional disorder can be distinguished from schizophrenia and schizophreniform disorder by the absence of the other characteristic symptoms of the active phase of schizophrenia Depressive and bipolar disorders and schizoaffective disorder These disorders may be distinguished from delusional disorder by the temporal relationship between the mood disturbance and the delusions and by the severity of the mood symptoms. If delusions occur exclusively during mood episodes, the diagnosis is depressive or bipolar disorder with psychotic features. Mood symptoms that meet full criteria for a mood episode can be superimposed on delusional disorder. Delusional disorder can be diagnosed only if the total duration of all mood episodes remains brief relative to the total duration of the delusional
Page 4 of 10 PSYCHIATRY 2 Schizophrenia Spectrum and Other Psychotic Disorders 1.1 June 19, 2014 Bautista, Cruz, Gillera, Janolo, Merilles disturbance. If not, then a diagnosis of other specified or unspecified schizophrenia spectrum and other psychotic disorder accompanied by other specified depressive disorder, unspecified depressive disorder, other specified bipolar and related disorder, or unspecified bipolar and related disorder is appropriate. BRIEF PSYCHOTIC DISORDER DIAGNOSTIC CRITERIA Criteria A. presence of the following symptoms.At least one of these should include 1-3: (1) delusions (2) hallucinations (3) disorganized speech (e.g., frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior Criteria B. duration of an episode is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning Criteria C. the disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to substance abuse Specify if:  With marked stressors (brief reactive psychosis): Sxoccur in response to events that are markedly stressful to almost anyone in similar circumstances in the individual‘s cultures  Without marked stressors: Sxdo not occur in response to events that are markedly stressful to almost anyone in similar circumstances in the individual‘s cultures  With postpartum onset: if onset is during pregnancy or within 4 weeks postpartum Specify if:  With catatonia Specify current severity  5 point scale ranging from 0(not present) to 4(present and severe)  Diagnosis of brief psychotic disorder can be made without using the severity specifier DIAGNOSTIC FEATURES  Essential feature is a disturbance that involves the sudden onset Criterion A  Sudden onset- change from a non-psychotic state to a clearly psychotic state within 2 weeks, without prodrome DEVELOPMENT AND COURSE  May appear in adolescence or in early adulthood  Average: mod 30s  Full remissio of all symptoms and an eventual full return to the premorbid level of functioning within 1 month of the onset of the disturbance RISK AND PROGNOSTIC FACTORS  Temperamental. Preexisting personality disorders may predispose to the development of the disorder DIFFERNTIAL DIAGNOSIS  Other medical conditions  Substance related disorders  Depressive and bipolar disorder  Other psychotic disorder  Malingering and factitious disorders  Personality disorders SCHIZOPHRENIFORM DISORDER DIAGNOSTIC CRITERIA Criteria A. 2 (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these should include 1-3: (1) delusions (2) hallucinations (3) disorganized speech (e.g., frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior (5) negative symptoms, i.e., affective flattening, alogia, or avolition Criteria B.An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as ―provisional‖. Criteria C. Schizoaffective disorder and depressive or bipolar 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, they have been present for a minority of the total duration of the active and residual periods of the illness Criteria D.The disturbance is not attributable to the physiological effects of a substance or other medical condition Specify if:  With good prognostic features: presence of at least 2 of the following features: o Onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning o Confusion or perplexity o Good premorbid social and occupational functioning o Absence of blunted or flat affect  Without good prognostic features: if two or more of the above features are not present Specify if:  With catatonia Specify current severity  5 point scale ranging from 0(not present) to 4(present and severe)  Diagnosis of schizophreniform disorder can be made without using the severity specifier DIAGNOSTIC FEATURES  Distinguished by its difference in duration(1-<6mth)  Diagnosis of schizophreniform is made under 2 conditions: o Episode of illness lasts between 1 and 6 months and the individual has already recovered o Individual is symptomatic for less than 6 months‘ duration required for the diagnosis of schizophrenia but has not yet recovered. In this case, dx should be schizophreniform disorder (provisional) because it is uncertain if individual will recover within 6 months DEVELOPMENT AND COURSE  Development similar to schizophrenia  1/3 of individuals with initial diagnosis of schizophreniform recover within 6 months RISK AND PROGNOSTIC FACTORS  Genetic and physiological. Relatives of individuals with schizophreniform have an increased risk for schizophrenia DIFFERNTIAL DIAGNOSIS  Other mental disorders and medical conditions  Brief psychotic disorder SCHIZOPHRENIA DIAGNOSTIC CRITERIA Criteria A. 2 (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these should include 1-3: (1) delusions (2) hallucinations (3) disorganized speech (e.g., frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior