schizophrenia spectrum/other psychotic disorders Flashcards
Brief Psychotic Disorder:
The diagnosis of brief psychotic disorder requires the presence of one or more of four characteristic symptoms for at least one day but less than one month, with at least one symptom being delusions, hallucinations, or disorganized speech. The four characteristic symptoms are delusions, hallucinations, disorganized speech (e.g., derailment, tangentiality), and grossly disorganized or catatonic behavior. [The DSM-5 defines a delusion as “a false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof of evidence to the contrary” (p. 819). It defines an hallucination as “a perception-like experience with the clarity and impact of a true perception but without the external stimulation of the relevant sensory organ” (p. 822) and notes that hallucinations must be distinguished from illusions, which occur when “an actual external stimulus is misperceived or misinterpreted” (p. 822).]
Schizophreniform Disorder
This diagnosis requires the presence of at least two of five characteristic symptoms for at least one month but less than six months, with at least one symptom being delusions, hallucinations, or disorganized speech. The five characteristic symptoms are delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (e.g., avolition, alogia, anhedonia).
Schizophrenia
The diagnosis of schizophrenia requires the presence of an active phase that lasts for at least one month and includes at least two of five characteristic symptoms, with at least one symptom being delusions, hallucinations, or disorganized speech. (The other two characteristic symptoms are grossly disorganized or catatonic behavior and negative symptoms). There must also be continuous signs of the disorder for at least six months that may include prodromal and/or residual phases in addition to the required active phase. Prodromal and residual phases consist of two or more characteristic symptoms in an attenuated form or negative symptoms only.
- Etiology: Schizophrenia has been linked to genetic factors and neurotransmitter and brain abnormalities. Evidence for a genetic contribution is provided by family studies which have found that, the greater the degree of genetic similarity, the greater the concordance rate (the likelihood that two people with shared genes will develop the same disorder). The concordance rates for first-degree relatives reported by Gottesman (1991) are listed below:
Relationship to Person with Schizophrenia
Concordance Rate
Parent
6%
Biological sibling
9%
Child of one parent with schizophrenia
13%
Dizygotic (fraternal) twin
17%
Child of two parents with schizophrenia
46%
Monozygotic (identical) twin
48%
Neurotransmitters that have been linked to schizophrenia include dopamine, glutamate, and serotonin. According to the original dopamine hypothesis, schizophrenia is due to high levels of dopamine or hyperactivity of dopamine receptors. Evidence for this hypothesis is provided by research showing that amphetamines increase dopamine activity and produce schizophrenia-like symptoms, while drugs that decrease dopamine activity reduce or eliminate these symptoms. A revised version of the dopamine hypothesis (Kuepper, Skinbjerg, & Abi-Dargham, 2012) predicts that the positive symptoms of schizophrenia are due to dopamine hyperactivity in subcortical regions of the brain (especially in striatal areas), while the negative symptoms are due to dopamine hypoactivity in cortical regions (especially in the prefrontal cortex).
Brain abnormalities associated with schizophrenia include enlarged ventricles and hypofrontality, which refers to lower-than-normal activity in the prefrontal cortex and is believed to contribute to the disorder’s negative and cognitive symptoms. One model of schizophrenia that’s consistent with the revised dopamine hypothesis described above implicates cortical and subcortical regions. It predicts that dysfunction in the temporal-limbic-frontal network causes the negative symptoms of schizophrenia as well as disinhibition in subcortical areas of the brain that, in turn, increases the release of dopamine in the striatum (caudate nucleus, putamen, and nucleus accumbens) and causes the positive symptoms (Hein, et al., 2003).
- Comorbidity: Common comorbid conditions include anxiety disorders, obsessive-compulsive disorder, and tobacco use disorder. With regard to the latter, the studies have found that about 70 to 85% of individuals with schizophrenia are tobacco users and, according to the DSM-5, over half of individuals with this diagnosis meet the diagnostic criteria for tobacco use disorder.
- Onset, Course and Prognosis: The psychotic symptoms of schizophrenia usually first appear between the late teens and early 30s, with the peak age of onset being in the early- to mid-20s for males and the late-20s for females. Psychotic symptoms often decrease with increasing age, while negative symptoms and cognitive symptoms persist. A better prognosis for schizophrenia is associated with female gender, an acute and late onset of symptoms, comorbid mood symptoms (especially depressive symptoms), predominantly positive symptoms, precipitating factors, a family history of a mood disorder, and good premorbid adjustment. In contrast, anosognosia (a lack of insight into or awareness of one’s disorder) is associated with non-adherence to treatment and an elevated risk for relapse. Patients whose family members are high in expressed emotion are also at increased risk for relapse. Expressed emotion refers to the emotional response of family members to a patient with schizophrenia or other mental disorder, and families high in expressed emotion are characterized by high levels of criticism and hostility toward and emotional overinvolvement with the patient (Butzlafff & Hooley, 1998).
The research has identified variations in the onset, course, and prognosis of schizophrenia across countries. For example, there’s evidence that patients living in non-Western developing countries are more likely than those living in Western industrialized countries to experience an acute onset of symptoms, a shorter course, and a higher rate of remission (e.g., Hopper & Wanderling, 2000). The studies have also found that an “immigrant paradox” applies to schizophrenia, alcohol use disorder, and a number of other psychiatric disorders. It occurs when “newly arrived immigrants have better health outcomes than much more acculturated immigrants (with longer US residence) or even US born natives of the same ethnicity” (Ajayi & Ajayi, 2008, p. 81).
- Treatment: The treatment of schizophrenia is multimodal and includes psychosocial interventions, an antipsychotic drug, and adjunctive medications to treat comorbid disorders. Evidence-based psychosocial interventions include assertive community treatment, cognitive-behavior therapy for psychosis, cognitive remediation for schizophrenia, family psychoeducation, social skills training, supported employment, and acceptance and commitment therapy.
Schizoaffective Disorder
The diagnosis of schizoaffective disorder requires concurrent symptoms of schizophrenia and a major depressive or manic episode for most of the duration of the illness, but with the presence of delusions or hallucinations for two or more weeks without mood symptoms.
Delusional Disorder
This diagnosis requires that (a) the person have one or more delusions for a duration of at least one month and (b) the person’s overall functioning has not been markedly impaired except for any direct effects of the delusion. The DSM-5 distinguishes between the following subtypes: (a) erotomanic (the person believes that another person is in love with him/her); (b) grandiose (the person believes he/she has great but unrecognized talent or insight); (c) jealous (the person believes his/her spouse or partner is unfaithful); (d) persecutory (the person believes he/she is being conspired against, spied on, poisoned, or maliciously maligned); and (e) somatic (the person’s delusion involves bodily functions or sensations).
