Schizophrenia Spectrum and Other Psychotic Disorders

Question 1

Schizophrenia

Answer 1

DSM 5

1. elimination of the special attribution of bizarre delusions and Schneiderian first rank auditory hallucinations (2 or more voices conversing).
2. two (2) criteria A symptoms are requred for any diagnosis of schizophrenia
3. addition of Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech.
4. At least one of these core ‘positive symptoms’ is necessary for a reliable diagnosis.

According to the DSM-5, (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) Schizophrenia is a disorder in which a person will experience gross deficits in reality testing, manifested with at least two or more the following symptoms, which must be present for at least one month (unless treatment produces symptom remission):

At least one symptom collectively referred to as positive symptoms: must be in categories 1, 2, or 3,

1. Delusions- strange beliefs and ideas which are resistant to rational/logical dispute or contradiction from others.
2. Hallucinations- typically auditory, or less frequently, visual.
3. Disorganized Speech- incoherence, irrational content.
4. Disorganized or Catatonic behavior- repetitive, senseless movements, or adopting a pose which may be maintained for hours. The individual may be resistant to efforts to move them into a different posture, or will assume a new posture they are placed in.
5. Negative symptoms- flat affect, amotivation, anergia, failure to maintain hygiene (American Psychiatric Association, 2013).

Question 2

Schizophrenia Subtypes

Answer 2

1. Eliminated subtypes: paranoid, disorganized, catatonic, undifferentiated and residual
2. Dimensional approach to rating severity for the core symptoms to capture the heterogeneity of symptom types and severity expressed across individuals with psychotic disorders.

Question 3

Schizophrenia cont.

Answer 3

1. Continuous distrubance of 6 months or more that includes at least one month of 2 or more active-phase symptoms (positive and/or negative symptoms).
   
   1. impairment in one or more areas of functioning such as school, work, interpersonal, self-care.

Positive Symptoms:

1. excess or distrotion of normal functions: delusions, hallucinations, disorganized speech, catatonic
2. delusions: false beliefs that are firmly held despite what everyone else believes
   
   1. persecutory
   2. referential
   3. bizarre
3. Hallucinations: may affect any sensory modality, auditory most frequent
4. Disorganized speech: loosening of associations, incoherences, slips from topics
5. catatonic bx: decreased motor activity and reduced reactivity to environmental stimuli.

**Negative Symptoms: **

• restriction in the range and intensity of emotions and other functions and include affective flattening,
• alogia (poverty of thought/speech) and
• avolition (restricted initiation of goal-directed bx).

Type I: (positive symptoms): relatively good premorbid functioning

favorable response to traditional antipsychotic meds, due to neurotransmitter abnormalities.

Type II: (negative symptoms), relatively poor premorbid adjustment and

a poor response to traditional antipsychotic meds, result of structural brain abnormalities.

Anhedonia: loss of interest or pleasure; dysphoric mood; abnormalities in motor bx; somatic complaints.

poor insight into their illness: Anosognosia, thus treatment non-compliance.

Substance Dependence, Nicotine dependence, but no evidence they ar emore violent or aggressive than others!

Question 4

Schizophrenia even more!

Answer 4

Gender/Age/Culture

1. slightly more men
2. men onset: 18-25/female onset 25-35
3. higher for blacks due to misdiagnosis: more likely to have hallucinations and delusions as symptoms of depression and other dx.
4. WHO International Pilot Study of Schizo: patients from developing countries much more likely to exhibit an acute onset of symptoms, shorter clinical course, and a complete remission.

Course/Prognosis

1. usually chronic and complete remission rare
2. over time, positive symptoms decrease, but negative symptoms increase
3. Better prognosis: good premorbid adjustment, acute and late onset, female, presence of precipitating event, brief duration of active-phase symptoms, illness insight, family history of mood disorder and no family history of Schizophrenia.

Prevalance/Etiology

1. genetic link is huge, general population is just .5-1.5.
2. bio sibling:10%, fraternal twin: 17%, identical 48%, Child with both parents impacted 46%.
3. relatives of people w/schizo at high risk of range of schizo spectrum dx (schizotypal personality dx).
4. Enlarged Ventricles most common.
5. smaller hippocampus, amygdala and globus pallidus.
6. Hypofrontality (less blood flow to frontal lobes): negative symptoms and decreased cognitive task performance.

Question 5

Dopamine Hypothesis

Answer 5

1. most widely accepted neurochemical theory for Schizo.
2. Elevated dopamine levels or oversensitive dopamine receptors: : : Schizo
3. Phenothiazines and other typical antipsychotics work by blocking dopamine receptors (thus, decrease in dopamine integration).
4. Amphetamines, which elevate dopamine, can cause or increase delusions, hallucinations and other psychotic symptoms.

Modifications to the Dopamine Hypothesis

• new findings of elevated norepinephrine and serotonin AND low GABA and glutamate in Schizo.
• Atypical antipsychotics do not block very well dopamine, but do block Serotonin and other receptors.
• so maybe a Serotonin sensitivity as well.
• Higher prevalence in winter births: more infectious disases and more Schizo.

Treatment:

1. traditional antipsychotics: eliminating positive symptoms, but severe side effects (tardive dyskinesia).
2. Atypicals: (clozapine) more helpful to reduce negative symptoms and less likely to cause tardive dyskinesia.
3. Meds are enhanced when combined with psychosocial interventions.
   
   1. Target high levels of Expressed Emotion (EE), which is linked to high relapse and rehospitatlization rates.
   2. high EE: critical/hostile or overprotective, symbiotic.
   3. Social skills training and supported employment also beneficial.

Question 6

Schizophrenia Subtypes

DSM 5

Answer 6

1. DSM IV subtypes: paranoid, disorganized, catatonic, undifferentiated and residual types are ELIMINATED due to low diagnositc stability, relaiability validity.
2. Dimensional approach to rating severity for the core symptoms of schizophrenia to capture the important heterogeneity of symptom types and severity expressed across individual with psychotic dx.

Question 7

1.0 Schizophreniform

Answer 7

1. Unlike Schizophrenia (over 6 months): disturbance is present for at least one month but less than six months and functional impairment (social, occupational) may be present but not required.
2. 2/3^rds go on to have full schizophrenia diagnosis.
3. better with insight and good pre-symptom functioning
4. worse with negative symptoms, lack of eye contact, and flat affect.

Question 8

2.0 Schizoaffective Disorder

Answer 8

1. Major mood episode be present for a majority of the disorder’s total duration after criteria A has been met.
2. longitudinal instead of cross-sectional diagnosis.
3. improves reliability/validity with evidence that patiences have both psychotic and mood symptoms.
4. MOOD: concurrent symptoms of schizophrenia but with major deression, manic, or mixed episodes.
5. ONSET: typically in early adulthood and prognosis is somewhat better than for Schizophrenia but worse than prognosis for a Mood Disorder.

Question 9

3.0 Delusional Disorder

DSM 5

Answer 9

1. Criterion A : no longer requires the delusions to be non-bizarre. So they can be bizarre (non-plausible vs. plausible events) .
2. Better demarcation between Delusional Dx from OCD and body dysmorphic disorder (both with delusional components).
3. Thus: symptoms must not be better explained by conditions such as OCD or body dysmorphic sx with absent insight/delusional beliefs.
4. No longer separates delusional dx from shared delusional dx (folie à deux).
   
   1. if criteria for delusional dx is met then the diagnosis is made
   2. If the not, but shared beliefs are present, then the diagnosis of “other specified schizophrenia spectrum and other psychotic disorder” is used.
5. Overal psychosocial functioning is not markedly impaired and any distrubance in functioning is directly related to the delusions (can’t leave house due to aliens/dogs).
6. types of dislusions: erotomanic, grandiose, jealous, persecutory, somatic.
   
   1. Unspecified: dominant delusions isn’t clearly defined by the types.

Delusions are generally categorized in 4 groups: bizarre, non-bizarre, mood-congruent and mood-neutral.

Bizarre delusions are strange and implausible, such as being vivisected by aliens, while

non-bizarre delusions are possible but unlikely, such as being under surveillance.

Mood-congruent delusions are false beliefs that are consistent with the patient’s mood if disordered, such as power and influence with mania and rejection and ostracism with depression.

Mood-neutral delusions are not related to the patient’s mood, such as having two heads or one arm.

Delusions have a great variety of themes, but certain recurrent themes have been identified (Spitzer, 1990). These include delusions of control, mind-reading, thought insertion, reference, persecution, grandeur, self-accusation, jealousy (Othello syndrome), romance or sexual involvement (erotomania), somatic change or disease or death (Cotard syndrome). Somatic delusions are associated with mood disorders and organic dementias, and may constitute their own diagnostic entity (body dysmorphic disorder) (Spitzer, 1990), while grandiose or persecutory delusions are often cardinal symptoms of schizophrenia and related disorders (Freeman, 2004).

Question 10

4.0 Catatonia

DSM 5

Answer 10

1. Same criteria are used to diagnose catatonia whether the context is a psychotic, bipolar, depressive or other medical dx or an unidentified medical dx.
   
   1. 3 catatonic symptoms (of 12)
   2. may be diagnosed as a specifier for depressive, bipolar, and psychotic dx
   3. or as a separate disagnosis in the context of another medical condition
   4. or as an other specified diagnosis.

Question 11

5.0 Brief Psychotic Disorder

Answer 11

Introduction

The DSM-5 identifies Brief Psychotic Disorder as a recurrent, transient thought disorder, which typically occurs in adolescence or young adulthood.

short duration, although it can result in increased risk of suicidality, or inability to perform self care

Symptoms of Brief Psychotic Disorder

thought disorder in which a person will experience short term, gross deficits in reality testing, manifested with at least one of the the following symptoms:

• *Delusions**- strange beliefs and ideas which are resistant to rational/logical dispute or contradiction from others.
• *Hallucinations**- auditory, or visual.
• *Disorganized Speech**- incoherence, or irrational content.
• *Disorganized or Catatonic behavior**- repetitive, senseless movements, or adopting a pose which may be maintained for hours. The individual may be resistant to efforts to move them into a different posture, or will assume a new posture they are placed in.

To fulfill the diagnostic criteria for Brief Psychotic Disorder, the symptoms must persist for at least one day, but resolve in less than one month.

eventual return to premorbid functioning.

onset often after an overwhelming stressor.