06: Schizophrenia & Other Psychotic Disorders

Question 1

What is psychosis?

Answer 1

• 3 ways to qualify:
  
  • Delusions
  • Hallucinations (perceiving stimulus in absence of actual external sensory stimulus that seems indistinguishable from such an experience in reality)
    
    • Most often auditory
  • Formal thought disorder
    
    • Loosening of associations
    • Word salad
    • Blocking
    • Neologism
• Exclusion criteria:
  
  • Other medical condition (e.g., brain tumor, hyperthyroidism)

Question 2

What is the differential diagnosis of psychosis?

Answer 2

1. Brief psychotic disorder
2. Delusional disorder
3. Schizophrenia
4. Schizophreniform disorder
5. Schizoaffective disorder
6. Manic episode with psychotic features
7. Major depressive episode with psychotic features

Question 3

What is a brief psychotic disorder?

Answer 3

• Delusions/hallucinations/FTD present for > 1 day and < 1 month
• Pt returns to full premorbid functioning after the episode
• Typically associated with emotional turmoil and lability, confusion, and severe impairment
• May occur with or without marked stressor (if marked stressor present, disorder also called brief reactive psychosis)

Question 4

What is a delusional disorder?

Answer 4

• Presence of one or more delusions for at least one month
• Hallucinations may be present, but are not prominent and are related to the delusional theme
• FTD, disorganized & catatonic behavior, negative sx not present
• Functioning not markedly impaired, apart from direct impact of delusions
• If mood episodes occur, they are brief relative to overall duration of the delusional periods

Question 5

What is catatonia, and what are its qualifiers?

Answer 5

Catatonia: marked decrease in reactivity to the environment

1. Catalepsy (passive induction of a posture against gravity)
2. Agitation ((not influenced by external stimuli)
3. Mutism (lack of verbal response)
4. Posturing (maintenance of a posture against gravity)
5. Grimacing
6. Echolalia (mimicking another’s speech)
7. Mannerism (odd, circumstantial caricature of normal actions)
8. Stupor (not actively relating to environment)
9. Negativism (opposition to instructions)
10. Echopraxia (mimicking another’s movements)
11. Waxy flexibility (slight resistance to positioning)
12. Stereotypy (repetitive, abnormally frequent, non-goal directed movements)

Mnemonic: CAMP GEMS NEWS

Question 6

What are negative symptoms?

Answer 6

1. Diminished emotional expression
   
   • Flat Affect
   • Reduced movements of head, hands or body
   • Lack of variations in speech pitch, volume, rhythm, and intonation
2. Avolition (decrease in motivated self-initiated purposeful activities)
3. Alogia (diminished speech output)
4. Asociality (lack of interest in social interactions)
5. Anhedonia

Mnemonic: 5 A’s

Question 7

What are various delusional disorder classifications?

Answer 7

Classified according to the delusion’s central theme:

1. Erotomanic: conviction that another person is in love with the individual
2. Grandiose: conviction of having great talent or insight, having made an important discovery or having special relationship with a prominent person
3. Jealous: convictionof having an unfaithful partner
4. Persecutory: conviction of being conspired against, cheated, spied on, followed, poisoned, maliciously maligned, harassed or obstructed in pursuit of goals
5. Somatic: conviction of abnormalities of bodily functions or sensations
6. Mixed

Question 8

What are the diagnostic criteria for Schizophrenia regarding the Active Phase (Criterion A)?

Answer 8

• At least 2 of the following are present for a significant portion of a 1-month period (can be less, if successfully treated):
  
  1. Delusions
  2. Hallucinations
  3. Formal thought disorder
  4. Grossly disorganized or catatonic behavior
  5. Negative symptoms
• At least one symptom must be 1/2/3
• Delusions and hallucinations are also referred to as positive symptoms; formal thought disorder is a disorganized symptom

Question 9

What are the diagnostic criteria for Schizophrenia regarding Functional Impairment?

Answer 9

Pertains to pt’s level of functioning:

• Impaired in at least one major area (work, interpersonal relations, self-care)
• Markedly below the level achieved prior to the onset of illness
• Impaired for a significant portion of time since the onset of illness

Question 10

What are the diagnostic criteria for Schizophrenia regarding duration?

Answer 10

• Continuous signs of illness must be present for at least 6 months
• Must include at least one month of active-phase symptoms
• May include periods of prodromal or residual symptoms

Question 11

What are the characteristics of prodromal and residual symptoms?

Answer 11

1. Negative symptoms
2. Attenuated “quasi-psychotic” experiences and thoughts:
   
   1. Overvalued ideas (e.g., paranoid ideation, ideas of reference)
   2. Unusual perceptual experiences (e.g., illusions)
   3. Odd thinking/speech (e.g., vague, circumstantial, overly-abstract)
   4. Odd behavior that is not grossly disorganized (e.g., mumbling in public)

Question 12

What is the time-course of prodromal and residual symptoms of schizophrenia?

Answer 12

• Prodromal symptoms occur prior to the onset of the disorder (i.e., determination is made in retrospect)
  
  • Can persist for several years
• Residual symptoms occur after the resolution of the active phase
  
  • Tend to last as long as the disorder is present

Question 13

What are the diagnostic criteria for schizophreniform disorder, and what is its prognosis?

Answer 13

• Duration > 1 mo and < 6 mos, including prodromal, active and residual phases
• Impaired social or occupational functioning not required
• Prognosis:
  
  • 1/3 completely recover
  • 2/3 ultimately diagnosed with schizophrenia or schizoaffective disorder

Question 14

Describe mood disorders with psychotic features.

Answer 14

• Delusions and hallucinations
• Mood congruent for mania (grandiose, paranoid)
• Mood congruent for depression (personal inadequacy, guilt, disease, death, nihilism, deserved punishment)
• May be mood incongruent (e.g., paranoid for depression)
• Formal thought disorder only occurs with mania (not MDE)

Question 15

Why is a manic episode with psychotic features difficult to diagnose?

Answer 15

• In the moment (i.e., cross-sectionally), can be indistinguishable from brief psychotic disorder as well as the active-phase of schizophreniform disorder and schizophrenia
• Past Hx and future course crucial to distinguish among these disorders

Question 16

What is the prevalence of the various psychotic disorders?

Answer 16

• Brief psychotic disorder: 0.1% (perhaps 9% of 1st onset psychosis)
• Delusional disorder 0.2%
• Schizophrenia: 1%
• Schizophreniform disorder: 0.2%
• All 1:1 gender ratio