Schizophrenia/Psychotic Disorders

An overview: psychotic disorders are still quite often misunderstood by individuals not involved in the care of such patients or not personally exposed to patients with the disorders. Psychotic disorders are characterized by a difficulty with reality testing – differentiating what is real from what is imagined, and the disorders may be characterized by false belief systems referred to as delusions and often by auditory and/or visual hallucinations. The individuals capacity to deal with their work is severely impaired during the occurrence of their disorders. While extreme environmental situations may produce psychotic symptoms, it is generally accepted that many of the psychotic disorders are attributable to a defect in brain chemistry and the way in which the brain processes its electrochemical impulses.

Schizophrenia – have two or more of the following symptoms for a significant period of time during a one month period. These include delusions or false beliefs that govern their decision making, hallucinations which are faulty sensory perceptions such as seeing, hearing (etc) stimuli that exist only in their fantasy, disorganized speech which is difficult to comprehend, chaotic or catatonic behavior and/or negative symptoms such as blunting of their emotional expression. Social and occupational functioning is severely impaired as may be their capacity for self-care. The symptoms are not due to a medical disorder, and the symptoms are not due primarily to a mood disorder.

There are chiefly five subtypes of schizophrenia:

1. Paranoid Type: preoccupation with delusions (false beliefs) or auditory hallucinations (perception of hearing voices which can be condemning or commanding).

2. Disorganized Type: disorganized speech, behavior and flat (blunt) affect (emotional expression) or inappropriate (to the context) emotional expression.

3. Catatonic Type: (can include) motoric immobility (statue like body position), stupor or cataplexy (patient can be put into position which they then maintain), or excessive agitation and without purpose, mutisim and/or negativism (refusing to respond to commands), peculiar voluntary body movements or grimacing, echolalia/echopraxia (repeating that which is said)

4. Undifferentiated Type: none of the symptoms are sufficient to be assigned exclusively to the first three types listed above, yet the patient meets the criteria for schizophrenia

5. Residual Type: an absence of paranoid, disorganized or catatonic symptoms but continuing evidence of schizophrenia by the presence of negative symptoms and often accompanied by odd beliefs and unusual perceptual experiences.

There are specifiers used after the patient has had symptoms of schizophrenia for at least one year after the onset of active-phase symptoms. These are described as episodice with interepisode residual symptoms when there are significant residual symptoms even between the episodes of schizophrenia. This can be further refined to prominent negative symptoms if the symptoms between episodes are negative. There is a specifier for no interepisode residual symptoms. A patient can have continuous symptoms or sontinuous symptoms with prominent negative symptoms. Or the patient may have a single schizophrenic episode in partial remission and with prominewnt negative symptoms. A patient can also have a single schizophrenic episode which is in full remission.

Schizophreniform Disorder is characterized by symptoms lasting at least a month but less than six months. The symptoms are identical (delusions, hallucinations, disorganized speech, disorganized behavior and negative symptoms). Like schizophrenia, one must be certain that the disorder is not due to a medical condition or drugs and that it is not part of a schizoaffective disorder. Schizophreniform Disorder is often accompanied by the specifier of having good prognostic features or without good prognostic features. Good prognosis is characterized by absence of the previously discussed flat/blunt emotions, having previously good social and occupational functioning, confusion/perplexity associated with the height of the episode, and onset of psychotic symptoms within the first four weeks of initial symptoms. Thus, good prognosis is often associated with the acute/suddenness of the onset.

Schizoaffective disorder is diagnosed when there has been an uninterrupted period of symptoms of schizophrenia which, as noted, may include delusions, hallucinations, disorganization of speech, disorganized or catatonic behavior and negative symptoms such as (affective flattening) blunted emotional expression. The patient displays these symptoms along with mood symptoms of a major depressive episode, a manic episode or a mixed episode and that during the period of the illness the patient has experienced delusions or hallucinations in the absence of these prominent mood symptoms. As with all schizophrenic and other psychotic disorders, it is imperative to be certain that these symptoms are not related to medication intake, drug abuse, or a physical disorder. And in schizoaffective disorder, there is a further subdivision of Bipolar and Depressive Types. The mood episode of the disorder are present for a substantial period of the active and residual periods of the illness.

Delusional Disorder involves potentially real life situations that are, however, unreal in the life of the patient. Thus, a person may, indeed, be poisoned, famous or followed, but this is not reality for the patient. These patients are not odd, eccentric or bizarre as we see in schizophrenia but instead falsely believe that important people are in love with them (Erotomanic Type) or that they (the patients) themselves are powerful, knowledgeable, or wealthy (Grandiose Type), that the person is being malevolently treated (Persecutory Type), that their sexual partner is unfaithful (Jealous Type), that they have a physical defect or medical condition (Somatic Type) or that they have symptoms of two or more of these subtypes (Mixed Type). Outside of their delusional beliefs, the individual may have an overall appearance of being functional with minimal impairment.

Brief Psychotic Disorder refers to symptoms lasting at least one day, but less than one month, and may include delusions, hallucinations, disorganized speech and either disorganized or catatonic behavior. This needs to be differentiatef from those who have a mood disorder such as major depressive disorder or bipolar disorder which sometimes presents with psychotic symptoms. A brief psychotic disorder may arise within four weeks of childbirth or caused by marked psychological stressors or can occur in the absence of a stressor. It is important to validate that this is not the result of a physical condition or substance use.

In Shared Psychotic Disorder (also called Folie a Deux) a delusion or false belief system develops in an individual who is closely involved with another individual who is demonstrably delusional. The second individual’s delusion is similar, if not identical, to that of the individual with whom they are involved. They essentially share the same delusional system. This can apply to couples, and it can apply to groups of individuals. This must be differentiated from those who are abusing similar psychoactive substances and.or who were, for example, schizophrenic before entering the relationship with the delusional individual.

Psychotic Disorders Due to [specific general medical condition] are characterized by hallucinations or delusions and can be the result of metabolic, neoplastic, or structural accident of the either the central nervous system or organ systems which impact the nervous system. History, laboratory findings and/or physical exam are used to determine the medical condition giving rise to the symptoms, and, ideally, a means of addressing the medical problem.

Substance-Induced Psychotic Disorder can occur With Onset During Intoxication by the drug or With Onset During Withdrawal from the drug. The symptoms occur within a month of the intoxication or withdrawal, and drug (and not a disease process) must be known to be the cause of the symptoms. Many drugs are capable of producing hallucinations and/or delusions when initiated or withdrawn. These include alcohol, amphetamines, cocaine, inhalants, sedatives, hypnotics (sleep agents), anxiolytics (“minor tranquilizers”) and numerous other compounds.