Schizophrenia Spectrum & Other Psychotic Disorders

Chapter 13: Schizophrenia Spectrum & Other Psychotic Disorders

Lecture Outcomes

• Define and describe the clinical description and symptoms of schizophrenia.
  • Positive symptoms
  • Negative symptoms
  • Disorganized symptoms
• Describe the clinical/diagnostic features of:
  • Schizophrenia
  • Schizophreniform disorder
  • Schizoaffective disorder
  • Delusional disorder
  • Brief psychotic disorder

Schizophrenia

• Serious psychiatric disorder characterized by psychotic episodes consisting of:
  • Perceptual disturbances (hallucinations)
  • Fixed false beliefs (delusions)
  • Disorganized thinking & communication
  • Disorganized behaviour
• Chronic course.
• Global functional deterioration between psychotic episodes.
• DSM-5-TR: Schizophrenia Spectrum & other Psychotic Disorders.

Clinical Description & Symptoms

• Schizophrenia Spectrum Disorders encompasses:
  • Positive Symptoms
  • Negative Symptoms
  • Disorganized Symptoms

Positive Symptoms

• Overt, productive symptoms.
• Active manifestations of abnormal behaviour.
• Refer to symptoms around distorted reality.
  • Delusions
  • Hallucinations
• 50-70% of people with schizophrenia experience these symptoms.

Delusions

• Disorder of thought content.
• Fixed false belief, unshakable through reasoning and out of keeping with a person’s cultural or religious context, maturity and intellect.
• Occurs in clear consciousness.
• Most common types:
  • Delusions of persecution: A belief that others have it in for you or wants to harm you.
  • Delusions of grandeur: A belief that you are special or have certain powers.
  • Delusions of reference: A belief that neutral or unrelated things have specific reference to you.

Hallucinations

• Perceptual disturbance.
• Experience of sensory events without environmental input.
• Most common types:
  • Auditory hallucinations: hearing voices or sounds in the absence of external stimulation (e.g. voices discussing the patient or giving instructions).
  • Visual hallucinations: seeing things in the absence of external stimulation (e.g. people, animals, objects, flashes or blobs).
  • Tactile hallucinations: having skin sensations when not being touched (e.g. sensation of insects crawling under the skin).
  • Somatic/bodily hallucinations: unexplained feelings in the body (e.g. heat in the spleen or cutting sensation in the bone marrow).

Negative Symptoms

• Absence or insufficiency of normal behaviour.
• 60% of people with schizophrenia experience these symptoms.
• Correlates with a poor prognosis, increased cognitive deficits and the occurrence of disorganization.
• Examples:
  • Avolition/apathy: inability to initiate and persist in activities.
  • Alogia: deficiency in the amount and content of speech.
  • Affective flattening: apparently emotionless demeanour when a reaction is expected or a lack of emotional expression.
  • Asociality: lack of interest in social interactions.
  • Anhedonia: inability to experience pleasure.
  • Attentional (and other cognitive) deficits: impairment in working memory & executive functioning, cognitive inflexibility, loss of abstract association.

Disorganized Symptoms

• Predicts a poorer prognosis and is associated with marked cognitive deficits.
• Include a variety of erratic behaviours that affect speech, motor behaviour and emotional reactions.
• Disorganized emotions
  • Inappropriate affect
• Disorganized thinking & speech
  • Poor insight
  • Illogical & incoherent speech
  • Loose associations
  • Tangentiality
• Disorganized behaviour
  • Strange, purposeless behaviour (e.g. hoarding)
  • Catatonia (specifier)
    • Ranges from agitation to immobility
    • Involves various inappropriate motor behaviours (e.g. stupor, cataplexy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, grimacing, echolalia, echopraxia)

DSM-5-TR Schizophrenia Spectrum & Other Psychotic Disorders

• Schizophrenia
• Schizophreniform Disorder
• Schizoaffective Disorder
• Delusional Disorder
• Brief Psychotic Disorder

Schizophrenia: Clinical Description & Diagnosis

• Two/more of the following symptoms present during a 1 month period (or less, if successfully treated):
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behaviour
  • Negative symptoms
• At least one symptom must be either delusions, hallucination or disorganized speech.
• For a significant portion of the time, the level of functioning is markedly below the level achieved prior to the onset.
• Continuous signs of the disturbance persist for at least 6 months
  • Must include at least 1 month of symptoms that meet full criteria
  • May include periods of prodromal/residual symptoms (only negative symptoms/ symptoms in attenuated form).
• Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out.
• Symptoms are not attributable to the effects of a substance or another medical condition.
• If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the diagnosis of schizophrenia can only be made if prominent hallucinations/ delusions are present.
• Specifier:
  • With catatonia

Schizophreniform Disorder: Clinical Description & Diagnosis

• Similar symptoms than that of schizophrenia.
• However, symptoms last at least 1 month, but less than 6 months.
• Specifiers
  • With good prognostic features – Presence of at least 2 of the following: rapid onset, confusion, good premorbid functioning, absence of blunted/flat affect.
  • Without good prognostic features – 2/more of the above features are not present
  • Catatonia
• Most patients resume normal lives.
• Some may eventually develop schizophrenia.

Schizoaffective Disorder: Clinical Description & Diagnosis

• Criteria for schizophrenia is met and at the same time symptoms of a major mood episode (major depressive or manic) are also present
  • For a depressive episode, depressed mood must be present
• Delusions or hallucinations occur for 2/more weeks in the absence of a major mood episode.
• Symptoms that meet the criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
• Disturbance is not attributable to the effect of a substance or another medical condition
• Specifiers
  • Bipolar type – manic episode is part of the presentation (however, major depressive episodes may also occur)
  • Depressive type – only major depressive episodes are part of the presentation
  • Catatonia
• Prognosis is similar than for people with schizophrenia

Delusional Disorder: Clinical Description & Diagnosis

• Presence of 1/more delusions for at least 1 month.
• Delusions are usually non-bizarre (compared to bizarre delusions in schizophrenia)
• Other criteria for schizophrenia has never been met
  • If hallucinations are present, they are not prominent and related to delusion
• Functioning is not markedly impaired and behaviour not obviously odd/bizarre.
• If major mood episode have occurred, they have been brief relative to the duration of the delusional periods.
• Symptoms are not attributable to the effects of a substance or another medical condition
• Symptoms are not better explained by another psychological condition
• Specifiers
  • Erotomanic type: believe another person (usually of higher status) is in love with you
  • Grandiose type: believe you have some great talent, power or insight
  • Jealous type: believe your spouse or sexual partner is unfaithful
  • Persecutory type: believe that you or (someone close) are being malevolently treated
  • Somatic type: involves bodily functions or sensations
  • Mixed type: no delusional theme predominates
  • Unspecified type: dominant delusional belief cannot be clearly determined or is not described in the specific types
• Better prognosis than schizophrenia

Brief Psychotic Disorder: Clinical Description & Diagnosis

• At least one/more of the following symptoms
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behaviour
• Do not include symptoms that is a culturally sanctioned response.
• Duration of an episode is at least 1 day, but less than 1 month.
• Eventual full return to premorbid level of functioning.
• Disturbance is not better explained by another psychological disorder
• Not attributable to the effects of a substance or another medical condition
• Specifiers
  • With marked stressor(s) (brief reactive psychosis) – symptoms occur in response to stressful events
  • Without marked stressor(s) – symptoms do not occur in response to stressful events
  • With post-partum onset – onset during pregnancy or within four weeks postpartum
  • With catatonia