Non-Affective Psychotic Disorders

Question 1

What is the biggest difference between the disorders in the schizophrenia spectrum and other psychotic disorders section?

Answer 1

The disorders in this section of the DSM-5 are all characterized by the presence of Psychotic Symptoms

The biggest differences between the disorders in this section relate to the:
- Number of symptoms
- Severity of symptoms
- Course of illness
- Presumed cause

Question 2

What are some DSM-5 schizophrenia spectrum and other psychotic disorders?

Answer 2

Schizoaffective disorder - a bridge between people who have affective disorders and those with psychotic disorders

Other unspecified or specified schizophrenia spectrum and other psychotic disorder

Brief psychotic disorder

Delusional Disorder

Catatonia

Schizotypal Personality Disorder

Schizophreniform Disorder

Schizophrenia

Substance Induced Psychotic Disorder

Question 3

What is other specified schizophrenia spectrum and other psychotic disorder?

Answer 3

Symptoms of psychosis that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

The symptoms do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class

Examples of presentations that can be specified using the “other specified” designation include the following:
1. Persistent auditory hallucinationsoccurring in the absence of any other features
2. Delusions with significant overlapping mood episodes:This includes persistent delusions with periods of overlapping mood episodes that are present for a substantial portion of the delusional disturbance (such that the criterion stipulating only brief mood disturbance in delusional disorder is not met) Key differential with schizoaffective disorder?
3. Attenuated psychosis syndrome:This syndrome is characterized by psychotic-like symptoms that are below a threshold for full psychosis (e.g., the symptoms are less severe and more transient, and insight is relatively maintained).
4. Delusional symptoms in partner of individual with delusional disorder:In the context of a relationship, the delusional material from the dominant partner provides content for delusional belief by the individual who may not otherwise entirely meet criteria for delusional disorder.

**Folie à deux includes several syndromes in which symptoms, particularly paranoid delusions, are transmitted from one person to one or more others with whom the apparent instigator is in some way intimately associated so that he or she and they come to share the same delusional ideas.

Question 4

What is other unspecified schizophrenia spectrum and other psychotic disorder?

Answer 4

Symptoms of psychosis that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

These symptoms do not meet the full diagnostic criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class

The clinician chooses not to specify the reason that the criteria are not meet for a specific schizophrenia spectrum and other psychotic disorder because there is insufficient information to:
- Evaluate course of symptoms
- Determine if symptoms are threshold

• They have psychosis but don’t fit neatly into the criteria

Question 5

What is Folie à Deux?

Answer 5

Shared psychotic disorder (folie à deux) is a rare disorder characterized by sharing a delusion among two or more people in a close relationship

The inducer (or primary) has a psychotic disorder with delusions that influences another nonpsychotic individual (induced or secondary) based on a delusional belief

It is commonly seen among two individuals, but in rare cases, can include larger groups. For example, it can occur in a family and is called Folie à Famille

Question 6

What are the risk factors for Folie à Deux?

Answer 6

The exact cause is unknown…

Length of the relationship: more common in long relationships (probably because it requires that the pair have a strong attachment to one another)

Nature of the relationship: The majority of cases reported are among family members. Most common: married or common-law couples, and the second most common is sisters

Social isolation: The pair tend to be socially isolated and the shared delusion by the induced or secondary is the only way to maintain a good relationship

Personality disorder:
Secondaries usually show features of a personality disorder

Untreated mental disorder in the primary: The most common diagnosis in the primary is Delusional Disorder (followed by schizophrenia and affective disorders)

Cognitive impairment: Secondaries often have low IQ

Life events: Stressful life events

Sex: The disorder is more common among females, both as a primary or secondary

Question 7

What is Brief Psychotic Disorder?

Answer 7

Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior

Note:Do not include a symptom if it is a “culturally sanctioned response”
- “Cultural paranoia” describes adaptive or healthy responses by individuals living in a society they perceive as “prejudiced”. I.e.: protecting self-esteem by blaming an external source for negative events

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 explained bymajor depressiveorbipolar disorder with psychotic featuresor another psychotic disorder suchasschizophreniaor catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition

Question 8

What is the diagnostic criteria for delusional disorder?

Answer 8

The presence of one (or more) delusions with a duration of 1 month or longer

A diagnosis of schizophrenia has been ruled out

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

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

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.

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).

• Usually the only symptom present
• Functioning pretty much normally
• Delusion is what is more prominent
• Sometimes directly related to stressors

Question 9

Can catatonia occur in several disorders?

Answer 9

Catatonia can occur in the context of several disorders, including neurodevelopmental, psychotic, bipolar, depressive disorders, and other medical conditions (i.e. autoimmune disorders)

Question 10

How is catatonia characterized in the DSMI-5?

Answer 10

a) Catatonia associated with another mental disorder (i.e., a neurodevelopmental, psychotic disorder, a bipolar disorder, a depressive disorder, or other mental disorder)

b) Catatonic disorder due to another medical condition

c) Unspecified catatonia

Question 11

What are the symptoms of catatonia?

Answer 11

The clinical picture is dominated by three (or more) of the following symptoms:

1. Stupor (i.e., no psychomotor activity; not actively relating to environment)
2. Catalepsy (i.e., passive induction of a posture held against gravity)
3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner)
4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia])
5. Negativism (i.e., opposition or no response to instructions or external stimuli)
6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity)
7. Mannerism (i.e., odd, circumstantial caricature of normal actions)
8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements)
9. Agitation, not influenced by external stimuli
10. Grimacing (i.e., odd facial expressions)
11. Echolalia (i.e., mimicking another’s speech)
12. Echopraxia (i.e., mimicking another’s movements)

Question 12

What are the origins of schizotypal personality disorder?

Answer 12

Sandor Rado (1953) initially introduced the term schizotype to represent vulnerability to a “schizophrenic phenotype”

He argued that because the liability for schizophrenia was genetically driven, this vulnerability could (and did) result in impairment ranging from mild to fully schizophrenic

It was the work of Paul Meehl, however, that really drove the field
- As president of the American Psychological Association in 1962 he presented his comprehensive theory about the genetic causes of schizophrenia
- This was a major departure from the widely-held belief that schizophrenia was primarily the result of a person’s childhood rearing environment (The schizophrenigenic mother…)

Question 13

What was schizotypal originally blamed on?

Answer 13

It was blamed on the mother not being nurturing enough.
Schizophrenia was believed to be a consequence of the way the mother raised you but Paul Meehl wanted to move away from this idea

Question 14

True or False: It was believed that you could have a milder form of schizophrenia

Answer 14

TRUE.

You can have a milder form of schizophrenia because you can have variations of the way schizophrenia presents itself

Question 15

What was Meehl’s Theory?

Answer 15

Meehl posited that a single dominant “schizogene” led to an underlying aberration in synaptic signal selectivity, which he called “hypokrisia”

This disrupted neural functioning produced disruptions in the way that the brain integrated information at a neural level and he referred to this as “schizotaxia”

In the presence of other genes (“genetic potentiators”) and disrupted social environments, this schizotaxia, led to the development of schizotypy (and by extension, schizophrenia).

In essence, He viewed schizotypy as the personality organization that resulted from schizotaxia and conveyed vulnerability for the development of schizophrenia

• Assumed that there was a single underlying gene that led to aberration in the way the brain is firing. There is something wrong with the way your brain is firing - hypokrisia

Question 16

How did Meehl define Schizotypy? Symptoms?

Answer 16

Meehl defined schizotypy as a personality showing:

• Ambivalence (a tendency to experience divergent emotions toward situations, objects, or people simultaneously)
• Aversive drift (heightened trait negative affect)
• Dereism (thinking illogically or away from reality)
• Autism (lack of, or awkward communication)
• Cognitive slippage (an inability to control associations made within the context of things such as dreams, creative thoughts and free association

Question 17

Was schizotypy a necessary precursor for the emergence of schizophrenia?

Answer 17

Schizotypy was a necessary, but not sufficient, precursor for the emergence of schizophrenia

Question 18

What did Meehl believe about the “schizogene”?

Answer 18

Meehl believed that only ~10% of the population carried the “schizogene” and thus, only a small percentage of the population could develop schizotypy…

• You had to have that dominant gene in order to develop schizophrenia, you need to have schizotypy to develop schizophrenia

Question 19

Was Meehl’s view on schizotypal disorder dimensional?

Answer 19

Only to a certain set of the population. 10% of the population

Question 20

What is the more modern view towards schizotypal personality disorder?

Answer 20

Schizotypy can be assessed in the full population – Not just 10% of people!

• Meehl: Quasi-dimensional view (It is dimensional in only a subset of the population
• Claridge: Fully dimensional view (It is dimensional across the entire population)
• As you get higher on the continuum you get closer to the schizotypal personality disorder.

When we talk about personality disorders, we’re talking about a pattern that develops as the personality is developing, disrupted aspects of personality but occurring during the entire course of development
- With disorders we’re talking about the way people are functioning

Question 21

When was the schizotypal personality disorder introduced?

Answer 21

This diagnosis was introduced in the third edition of the DSM

Question 22

What was schizotypal personality disorder designed to describe?

Answer 22

• It was designed to describe the attenuated schizophrenia symptoms often observed in biological relatives of individuals with schizophrenia
• Subsequent research demonstrated that SPD and schizophrenia, as both Meehl and Claridge suggested, share similar neurobiological and environmental risk factors, suggesting shared genetic and other etiologic origins

When we look at theri background there tends to be a great deal of overlap, so the risk factors for these disorders are similar

Question 23

What is the dimensional models for personality disorders?

Answer 23

• “The diagnostic approach used in this manual represents the categorical perspective that personality disorders are qualitatively distinct clinical syndromes. An alternative to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another.”
• However, the DSM-5 then goes on to recognize Schizotypal Personality Disorder in the Schizophrenia Spectrum and Other Psychotic Disorders category!!
• They note in their description of the Personality Disorders that the dimensional view is under active investigation

Question 24

What is the confusion schizotypal personality disorder listed as?

Answer 24

“Schizotypal personality disorder is noted within this chapter as it is considered within the schizophrenia spectrum, although its full description is found in the chapter “Personality Disorders.”

• The diagnosis schizotypal personality disorder captures a pervasive pattern of social and interpersonal deficits, including reduced capacity for close relationships; cognitive or perceptual distortions; and eccentricities of behavior, usually beginning by early adulthood but in some cases first becoming apparent in childhood and adolescence. Abnormalities of beliefs, thinking, and perception are below the threshold for the diagnosis of a psychotic disorder.

Question 25

What is the diagnostic criteria schizotypal personality disorder?

Answer 25

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: - Ideas of reference (excluding delusions of reference). - Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations). - Unusual perceptual experiences, including bodily illusions. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped). - Suspiciousness or paranoid ideation. - Inappropriate or constricted affect. - Behavior or appearance that is odd, eccentric, or peculiar. - Lack of close friends or confidants other than first-degree relatives. - Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. - Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

Question 26

What differentiates schizotypal from schizophrenia or other psychotic disorders?

Answer 26

Pervasiveness Course Functioning - there isn't a big difference in functioning for those with schizotypal

Question 27

What is the diagnostic heterogeneity for schizotypal?

Answer 27

Because the diagnosis requires any five of nine symptoms, there are 256 symptom combinations that merit this diagnosis!! This allows for A LOT of clinical variability between individuals diagnosed with this disorder!

Question 28

What is the course of illness for schizotypal personality disorder?

Answer 28

Schizotypal personality disorder has a relatively stable course Only a small proportion of individuals go on to develop schizophrenia or another psychotic disorder

Question 29

Schizotypal personality may be apparent in childhood and adolescences with...?

Answer 29

Schizotypal personality disorder may be first apparent in childhood and adolescence with: - Solitariness - Poor peer relationships - Social anxiety - Underachievement in school - Hypersensitivity - Peculiar thoughts and language - Bizarre fantasies Generally, these children typically just appear “odd” or “eccentric” and attract teasing BUT in some cases, it can be quite severe…

Question 30

Is there an overlap between schizotypal personality disorder and the autism spectrum?

Answer 30

There are a lot of overlap in presentation? Some might just get the autism diagnosis because it's the easier one to give children and there are a lot of overlap Making the distinguish is hard and you cannot diagnose both

Question 31

What features of schizotypal personality disorder are shared with ASD?

Answer 31

Eccentric behavior, inappropriate affect and off thinking, and speech (in SDC, associated with fantasies, paranoid ideas and perceptual disturbances.) Social and interpersonal deficits (in SDC, interaction is sought but distorted by fantasies, paranoid ideas and perceptual disturbances).

Question 32

What features of schizotypal personality disorder are specific to SDC (schizotypal personality disorder in childhood)?

Answer 32

Preoccupation with odd beliefs, bizarre fantasies and magical thinking, Suspicious and paranoid ideas and ideas of references Perceptual disturbances including auditory hallucinations and bodily illusions Social anxiety associated with paranoid fears

Question 33

Is schizotypal disorder treated the same as schizophrenia?

Answer 33

Individuals with schizotypal personality disorder often seek treatment for the associated symptoms of anxiety or depression NOT for the personality disorder features There is currently only limited evidence on which to base treatment decisions in this disorder Cognitive Behavioral Therapy (CBT) is typically the first treatment suggested Low dose antipsychotic medication may be used but problematic in child and adolescent patients…

Question 34

What are the periods of illness?

Answer 34

The beginning Active illness Residual Phase

Question 35

What is the beginning of periods of illness?

Answer 35

Prodromal phase - Loss of interest in usual activities - Withdrawal from friends and family - Confusion - Trouble concentrating - Feeling listless and apathetic - Prefer to spend most of their days alone - Preoccupation with religion or philosophy

Question 36

What is the active illness period of illness?

Answer 36

- Continuation of prodromal symptoms plus... - Delusions - Hallucinations - Marked distortions in thinking - Disturbances in behavior

Question 37

What is the residual phase of periods of illness?

Answer 37

After an illness - May be similar to the prodromal phase - Listlessness - Trouble concentrating - Withdrawal

Question 38

True or False: Everyone who eventually meets the schizophrenia diagnostic criteria first meets criteria for Schizophreniform Disorder

Answer 38

TRUE

Question 39

What is schizophreniform Disorder?

Answer 39

Schizophreniform disorder is a time-limited diagnosis that can be a precursor to developing schizophrenia * This is often the diagnosis given when someone is experiencing their “first episode” of psychosis

Question 40

What is the diagnostic criteria for schizophreniform disorder?

Answer 40

A. Two (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 must be (1), (2), or (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., diminished emotional expression or avolition) 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.” C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic 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. D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Question 41

Will those diagnosed with schizophreniform disorder go on to develop a diagnosis of schizophrenia?

Answer 41

~1/3 to 1/2 of those diagnosed with this disorder will NOT go on to a diagnosis of Schizophrenia. These patients tend to have good prognostic features including acute onset and good premorbid functioning

Question 42

Why are we examining schizophrenia?

Answer 42

It is: - The most severe psychotic disorder - The most debilitating psychotic disorder - The disorder that has been most studied - The disorder from which all of the other psychotic disorders have been “carved”

Question 43

Why is schizophrenia the prototypical psychotic disorder?

Answer 43

- It is the most common form of psychosis - Tends to involve abnormalities in all five of the psychotic symptom domains: hallucinations, delusions, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms - It tends to begin during a predictable stage of development - late adolescence and early adulthood

Question 44

What is the diagnostic criteria for schizophrenia?

Answer 44

A. Two (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 must be (1), (2), or (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., diminished emotional expression or avolition) B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic 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. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Question 45

If there is a history of autism spectrum disorder or communication disorder of childhood onset can you still make a schizophrenia diagnosis?

Answer 45

If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made ONLY if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).