Schizophrenia Spectrum and other Psychotic Disorders

Question 1

Schizophrenia Spectrum and Psychotic Disorders

Answer 1

Defined by abnormalities in one or more of 5 domains

1. delusions
2. hallucinations
3. disorganized thinking
4. grossly disorganized or abnormal motor behavior (including catatonia) and negative symptoms
5. negative symptoms

Question 2

Delusions

Answer 2

Fixed beliefs not amenable to change in light of conflicting evidence. Delusional content may include a variety of themes like persecutions, referential, somatic, relies, grandiose.

Question 3

Persecutory Delusions

Answer 3

Belief that one is going to be harmed, harassed, by an individual, organizations, or other group

Question 4

Grandiose Delusions

Answer 4

When an individual believes that they have exceptional abilities, wealth or fame.

Question 5

Erotomaniac Delusions

Answer 5

Individual believes falsely that another person is in love with them

Question 6

Nihilistic Delusion

Answer 6

Conviction that a major catastrophe will happen.

Question 7

Somatic Delusion

Answer 7

Preoccupation regarding health and organ function.

Question 8

Bizarre Delusions

Answer 8

Clearly implausible and not understandable to same-culture peers and do not derive from oridinary life experiences.

Question 9

Hallucinations

Answer 9

perception-like experiences that occur without an external stimulus. Vivid and clear, with full force impact of normal perceptions and not under voluntary control. They can occur in any sensory modality, but auditory hallucinations are most common in schizophrenia.

Question 10

Auditory Hallucinations

Answer 10

Experienced as voices and can be familiar or unfamiliar. They are perceived as distinct from the individuals own thoughts. They must occur in clear sensorium, rather than when falling asleep (hypnogogic), or waking up (hypnopompic).

Question 11

Disorganized Thinking (Speech)

Answer 11

Disorganized thinking can be inferred from speech patterns. Derailment or loose associations (switching from topic to topic). Answers to questions my be vaguely related or or completely unrelated (tangentiality).

Question 12

Incoherence or word salad

Answer 12

Severely disorganized speech that resembles receptive aphasia.

Question 13

Grossly Disorganized or Abnormal Motor Behavior

Answer 13

Range of behaviors that can look like childlike silliness to unpredictable agitation. Problems may occur in goal directed behavior that affects ADL’s.

Question 14

Catatonic Behavior

Answer 14

Decrease in reactivity to the environment. This behavior ranges from negativism or resistance to instructions, to maintaining a rigid, inappropriate or bizarre posture, to a complete lack of verbal and motor responses (mutism or stupor). Stereotyped movements, grimacing, staring, mutism and echoing speech. Catatonic symptoms are not exclusive to Schizophrenia.

Question 15

Negative Symptoms

Answer 15

1. Diminished emotional expression: reductions in the expressions of emotion in the face like eye contact, intonation of speech (prosody), and movements of the hand, head and face that normally give an emotional emphasis to speech.
2. Avolition: is a decrease in motivated self-initiated purposeful activities. Individual may sit for long periods of time and show little interest in participation of social activities or work.

Question 16

Alogia

Answer 16

Diminished speech output

Question 17

Anhedonia

Answer 17

Decreased ability to experience pleasure from positive stimuli or a degradation in the recollections of pleasure previously experienced.

Question 18

Asocialty

Answer 18

Apparent lack of interest in social interactions and be associated with avolition.

Question 19

Schizotypal Personality Disorder 301.22 (F21)

Diagnostic Criteria

Answer 19

Primary rule out for Schizophrenia
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 5 or more of the following:
1. Ideas of reference (excluding delusions of reference)
2. Odd beliefs, magical thinking that influences behavior
3. Unusual perceptual experiences including body illusions. Could be sensing that someone is there are hearing a faint voice whispering their name.
4. Odd thinking and speech (vague, circumstantial, metaphorical, overelaborate).
5. Suspicious or paranoid ideation
6. Inappropriate restricted affect which negatively affects relationships
7. Behavior or appearance that is odd, eccentric or peculiar
8. Lack of close friends or confidants
9. Excessive social anxiety that does not diminished with familiarity and tends to be associated with paranoid fears rather than negative judgements about self.
B. Does not occur during the course of schizophrenia, bipolar, or depressive disorder with psychotic features

Question 20

Schizotypal Disorder Diagnostic Features

Answer 20

Pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships. Cognitive or perceptual distortions and eccentricities of behavior.

Question 21

Ideas of Reference

Answer 21

Incorrect interpretations of casual incidents and external events as having a particular and unusual meaning specifically for the person. Superstitious preoccupation and interest in paranormal phenomena which fall outside of the norms of their culture or subculture, is common.

Question 22

Delusional Disorder 297.1 (F22)

Diagnostic Criteria

Answer 22

A. The presence of 1 or more delusions with a duration of 1 month or longer
B. Criteria (A) of schizophrenia never met
(A) Delusions, Hallucinations, Disorganized speech, Grossly disorganized or catatonic behavior, Negative symptoms
C. Apart from the impact of the delusions or its ramifications, functioning is not markedly impaired and behavior is no 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.

Question 23

Delusional Disorder Diagnostic Specifiers

Answer 23

Specify type:
Erotmaniac
Grandiose
Jealous type
Persecutory type
Somatic type
Mixed type
Unspecified type
Specify if: bizarre content
Specify if after 1 year of symptoms: 
First episode, acute
First episode, partial remission/full remission
Multiple episodes acute/partial remission/full remission
Continuous
Specify current severity: rated by a qualitative assessment of the primary symptoms of psychosis including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, negative symptoms,
Use 5-point rating scale from Clinical-Rated Dimensions of Psychosis Symptom Severity

Question 24

Delusional Disorder Differential Diagnosis

Answer 24

OCD with absent insight
Delirium, major neurocognitive disorder, psychotic disorder due to another medical condition, substance induced
Schizophrenia/schizophreniform
Depressive and bipolar disorder and schizoaffective disorder: distinguished by the temporal relationship between the mood disturbance and the delusions and by the severity of the mood symptoms. If the delusions occur exclusively during mood episodes, the Dx is depressive or bipolar disorder with psychotic features. Mood symptoms must be brief in relationship to the delusional content to be delusional disorder.

Question 25

Brief Psychotic Disorder 298.8 (F23)

Diagnostic Criteria

Answer 25

A. Presence of 1 (or more) of the following symptoms and at least 1 must be from 1-3:
1. Delusions
2. Hallucinations
3. Disorganized Speech
4. Grossly disorganized or catatonic behavior
B. 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
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 not attributable to the physiological effects of a substance or other medical condition

Question 26

Brief Psychotic Disorder Diagnostic Specifiers

Answer 26

Specify if:
with marked stressors–ie. brief reactive psychosis
without marked stressors: not in response to an event
with permpartum onset
with catatonia (must use additional coding note)
Specify current severity:
rated by a quantitative assessment of the primary symptoms of psychosis including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, negative symptoms

Question 27

Brief Psychotic Disorder Diagnostic Features

Answer 27

Sudden onset is defined as a change from a non-psychotic state to a clearly psychotic state over 2-week period. An episode lasts at least 1 day but less than 1 month.

Question 28

Brief Psychotic Disorder Development and Course

Answer 28

Average age of onset mid 30’s. By definition, a diagnosis of brief psychotic disorder requires a full remission of all symptoms and an eventual full return to premorbid level of functioning within 1 month of symptom onset.

Question 29

Brief Psychotic Disorder Differential Dx

Answer 29

Other medical conditions
Substance related
Depressive/bipolar–if there is a mood episode than a brief psychotic dx cannot be made
Other psychotic disorders–if symptoms persist for more than 1 month (schizophreniform, delusional disorder, MDE with psychoses)
Recurrence could indicate bipolar, recurrent acute exacerbations of schizophrenia

Question 30

**Schizophreniform Disorder 295.40 (F20.81)
Diagnostic Criteria
Characteristic symptoms look like schizophrenia and the differentiator is duration: more than 1 month but less than 6 months. Can have diagnosis without impairment in social or occupational functioning

Answer 30

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 1 symptom must come from 1-3.
1. Delusions
2. Hallucinations
3. Disorganized speech (derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
B. An episode of the disorder lasts at least 1 month but less than 6 months. Call it provisional if a dx must be made before recovery.
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 of symptoms, 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 or another medical condition.

Question 31

Schizophreniform Disorder Diagnostic Specifiers

Answer 31

Specify if: good prognostic features (onset of psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or function, confusion or perplexity, good premorbid social and occupational function, absence of blunted affect)
Specify if: without good prognostic features
Specify if: catatonia
Specify current severity

Question 32

Schizophrenia 295.90 (F20.9)

Diagnostic Criteria

Answer 32

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 1 symptom must come from 1-3.
1. Delusions
2. Hallucinations
3. Disorganized speech (derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
B. For a significant portion of the time since onset of the disturbance, level of functioning is one or more major areas, such as work, interpersonal relationship, or self care is markedly below the level achieved prior to the onset
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 meat criteria A (active-phase symptoms) and may include prodromal or residual symptoms. During these prodromal or residual periods, the sign of the disturbance may be manifested by only negative symptoms or by tow or more symptoms listed in Criteria Present in an attenuated form (ex. odd beliefs, unusual perceptual experiences).
D. Ruled out schizoaffective disorder/bipolar (looking at mood component)
E. Not attributed to a substance
F. No history of autism spectrum or communication disorder

Question 33

Schizophrenia Active Phase

Answer 33

A period in the course of schizophrenia in which psychotic symptoms are present

Question 34

Positive Symptoms

Answer 34

The symptoms of schizophrenia that represent exaggerations or distortions of normal thoughts, emotions and behavior. These would be Criteria A 1-4:
delusions, hallucinations, disorganized speech, disorganized behavior or catatonia

Question 35

Negative Symptoms

Answer 35

Functioning that is below normal. Represented by A(5) and are characterized by avolition (lack of motivation), asociality (lack of social interest), restricted affect which is narrowing of range of emotional expression.

Question 36

Schizoaffective Disorder

Answer 36

Individuals with depressive or bipolar disorder also experience delusions and/or hallucinations and meet schizophrenia criteria. This diagnosis can only be made if there is a 2-week period where there are psychotic symptoms but an absence of mood symptoms.