Psychotic Disorders





1. Introduction to the psychotic disorders


  • Psychotic disorders are mental disorders that can cause abnormal thinking and one's ability to perceive normally. Many who experience psychoses lose touch with reality and are unable to cope with the outside world.
  • Some of the major symptoms associated with psychotic disorders include:
    delusions, hallucinations, incoherent or disorganized speech, tangentiality, loose associations or derailment, preservation, alogia, avolition, bizarre behavior, and/or disorganized behavior.


  • There are several types of psychotic disorders but one which is reported frequently is schizophrenia.
    Schizophrenia affects people from all walks of life; and is about as prevalent as epilespy. This psychotic disorder usually begins in late adolescence or early adulthood.
  • Schizoaffective disorder is a disorder, that when diagnosed, an individual demonstrates symptoms of both Schizophrenia and a severe mood disorder: bipolar or unipolar.
  • Another example of schizophrenia is Schizophreniform disorder. This disorder can last up to six months. The indiviual may experience social and occupational impairment during the episodes and a brief psychotic disorder. If the symptoms of brief psychotic disorder last for a month or longer, they will turn into one of the other disorders previously listed.
  • There are two types of symptoms that coincide with schizophrenia; postive and negative symptoms.
    Postive symptoms include delusions, hallucinations, disorganized speech, and disorganized or catatonic behavior. Negative symptoms are those who experience the flat effect, alogia, and avoltion

The following links come from a series of five videos uploaded by ehowhealth regarding schizophrenia:
1. What is Schizophrenia?
2. Signs of Schizophrenia in children with ADHD
3. How is Schizophrenia diagnosed?
4. Schizophrenia and homelessness
5. Is Schizophrenia inherited?
Links

  • The following video is from MTV's True Life series. It follows three different young people diagnosed with different Schizophrenic disorders.
  • The following video explains what steps to use if family member were to be experiencing symptoms regarding psychotic disorders.








2. Schizophrenia, Paranoid Type (295.30)


    • DSM-IV-TR criteria
      • A. Characteristic symptoms:
        Preoccupation with one or more delusions or frequent auditory hallucinations. None of the following is present: disorganized speech, disorganized/ catatonic behavior, flat/ inappropriate affect.
        • Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

      • B. Social/occupational dysfunction:
        For a significant portion of the time since the onset of the disturbance one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).


      • C. Duration:
        Continuous signs of the disturbance that 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 two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).


      • D. Schizoaffective and Mood Disorder exclusion:
        Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either
        • (1) no Major Depressive Episode, Manic Episode, or Mixed Episode have occurred concurrently with the active-phase symptom
          or
        • (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

      • E. Substance/general medical condition exclusion:
        The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.


      • F. Relationship to a Pervasive Developmental Disorder:
        If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated)


      • For the paranoid subtype, the above criteria must be met, but one must have a preoccupation with one or more delusions or frequent auditory hallucinations and none of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

    • Hitler as an example:
      • The DSM-IV-TR has 5 diagnostic criteria for schizophrenia.
      -The first is the characteristic symptoms in which two of the following five must be present: (1) delusions, (2) hallucinations, (3) disorganized speech, (4) grossly disorganized or catatonic behavior, (5) negative symptoms such as affective flattening, alogia, or abolition.
      Hitler had two of these. He had delusions that people were out to hurt him; delusions that the Jews were evil, unclean, and the cause for all of chaos and downfall of Germany; delusions that he was a wonderful artist, possibly one of the best of the time; delusions that he was all powerful and deserving.
      • The second symptom Hitler demonstrates is negative symptoms of affective flattening. The only time Hitler showed any type of appropriate emotion was when he was angry. The second criterion is social or occupational dysfunction. Hitler was able to gain millions of followers but he rarely had true good relations with friends or family. Also considered is the duration, continuous signs for at least six months with at least one month of straight symptoms. Hitler portrayed these symptoms from young adulthood onward. Other criteria considered are ones of exclusion, exclusion of schizoaffective and mood disorders, exclusion of substance or general medical conditions, and exclusion of pervasive development disorders.
        It may also be possible that Hitler had Cyclothymic Disorder, which is a mild form of bipolar disorder where a person has mood swings from mild to moderate depression to euphoria, but stays connected to reality.
        DSM-IV-TR states that the essential feature of Paranoid type Schizophrenia is the presence of prominent delusions or auditory hallucinations in relation to preservation. The delusions are usually of grandiose theme. Hitler had many delusions about the Jew being evil and out to harm and infect everyone. Hitler often believed that he was a better artist and architect than he was and was appalled when others did not find him so. He believed he was better than everyone else, even while homeless living in the Men’s Shelter.
        Associated features include anxiety, anger, aloofness, and argumentativeness, most of which Hitler displayed in almost every way. According to the DSM-IV-TR it may have been possible that Hitler had schizophrenia paranoid type.

    • Associated features
      • The paranoid subtype is the most common of subtypes. Those with the paranoid subtype will have delusions and suspicions that increase during the course of the illness. Their delusions are mostly persecutory, grandiose, or feelings of inadequacy, and will tend to have interpersonal problems. The delusions may be multiple, but usually have a theme. Other features include anxiety, anger, aloofness, and argumentativeness.These features become increasingly suspicious of relatives and close friends. The indiviual may display a superior or patronizing manner, and may be extremely formal or intense in their interactions. They function at a higher level than most other schizophrenics because of the lack of negative symptoms. Their diagnosis is more stable than for the other types, and they respond better to treatment as well. Individuals suffering from the paranoid subtype also suffer from social withdrawal and persistently hold grudges and perceive attacks.
    • Child vs. adult presentation
      • The illness is presented much the same for adults as for children, except the symptoms appear before age 12. The illness manifests itself gradually in children and is often preceded by lags in motor development, speech development, etc. The paranoid subtype often manifests itself later than the other subtypes. If there is an onset of Schizophrenia in childhood or adolescence, a failure to achieve an expected level of interpersonal, academic, or occupational achievement is thought to occur. His or her social and occupational functioning needs to be on a steady decline during the disorder.
    • Gender and cultural differences in presentation
      • Schizophrenia presents itself three to six years later in women than in men, but it presents itself the same way between genders. Schizophrenic disorders present themselves consistently across the world, but one must take into account cultural attitudes on the symptoms which typically make up schizophrenia. In other words, what we see as symptoms of paranoia may be normal behavior to different cultures. Recent studies show that men are more likely to receive treatment for the disorder. In fact, most research on the treatment of schizophrenia is conducted on samples ranging from 60% to 100% male. Misdiagnosis of mood disorders as schizophrenia is the most common problem with the diagnosis of ethnic minorities in the United States.
    • Epidemiology
      • Schizophrenia has a lifetime prevalence of about 1%, and that prevalence may differ greatly from country to country. It is diagnosed disproportionately among the lower class. There is very little epidemiological data for Paranoid Schizophrenia specifically.
      • When the diagnosis of Schizophrenia came in use, almost half were considered in the Paranoid category. Now, new drugs can help decrease the paranoia and this diagnosis is on the decrease.
    • Etiology
      • Etiological factors for schizophrenia include genetic factors, environmental factors, and physiological factors.
        The more severe a parent’s schizophrenia, the more likely it is that a child will have schizophrenia. Monozygotic twins have a 46% concordance rate for schizophrenia, and dizygotic twins have a 9% concordance rate. There is also a lower fecundity level (the ability to produce viable offspring) for schizophrenics: a 70% reduction in males and a 30% reduction in females.
        Paranoid Schizophrenia does not seem to be as affected by genetics as the other subtypes.
      • There are also many environmental factors which could lead to schizophrenia.
        Such factors include living in an urban environment, a lower social economic status, and childhood experience of abuse or trauma.
        Since concordance rates are not at or near 100%, it is certain that there are many environmental factors which play into schizophrenia. Adoption studies have shown that a healthy family environment can serve as a protective factor from schizophrenia.
        Poor parenting is not held responsible for schizophrenia, but might increase the risk.
        The diathesis stress model is accepted by many psychologists as an explanation for the development of schizophrenia. This model states that the person is born with a genetic vulnerability to Schizophrenia and is afterward exposed to a traumatic event with which he/she cannot cope. If the person can effectively handle the stress brought about by the trauma, Schizophrenia may never develop.
        There are also some prenatal factors which influence the development of Schizophrenia. These factors include prenatal exposure to influenza, malnutrition, and birth complications.
      • There are also some physiological factors to consider:
        One hypothesis states that Schizophrenia is caused by excess levels of dopamine. Some say that the dopamine receptors may have become hypersensitive.
        There are some problems with this hypothesis. There are schizophrenics who do not respond to dopamine-decreasing drugs. Also behavior changes in schizophrenics occur over time, while dopamine receptors are effective usually within a few weeks. Schizophrenics also have anatomical differences in their brains. The total brain mass is less than average, and the ventricles are enlarged.
        Paranoid schizophrenics do not show these neuropsychological differences.
    • Empirically supported treatments
      • The two modalities of treatment for Schizophrenia are psychotherapy and anti-psychotic medication.
        Psychotherapy for Schizophrenia focuses on making changes that will be effective over time. Family therapy has been shown to have a positive outcome on the schizophrenic and to help the family cope with the disorder. The family is educated about the disorder and taught what to expect and how to handle different situations that the illness may present. They also learn how to improve communication between each other and the schizophrenic.
        Social Skill Training teaches the schizophrenic to improve on the social skills he or she may be lacking, and the difference between acceptable and unacceptable behavior. In Assertive Community Treatment, an interdisciplinary team provides skills training, rehabilitation, education, and support so that the schizophrenic can be kept in the community as opposed to being hospitalized. Schizophrenics are also taught to recognize indicators of stress and how to cope with them effectively. For those who cannot reach the point of being able to be without sheltered care, token economies have been shown to be useful. Tokens are given in return for desirable behaviors which have been laid out and are exchanged after a period of time for snacks or privileges. Inappropriate behaviors are ignored and are punished only when necessary. All of these treatments are used in combination with anti-psychotic medications
      • Anti-psychotic medications for Schizophrenia include: Clozaril, Compazine, Etrafon, Haldol, DecanoateInapsine, Lidone, Loxitane, Mellaril, Moban, Navane, Orap, Permitil, Prolixin, Decanoate, Enanthate, Proketazine, Risperdal, Serentil, Sparine, Stelazine, Taractan, Thorazine, Tindal, Trilafon, and Vesprin.
        Paranoid Schizophrenia responds very well to medication and has the best prognosis of all the subtypes.
      • Antipsychotic side effects include: motor side effects, for example pseudoparkinsonism (shake uncontrollably), bradykinesia, rigidity, & tardive dyskinesia, seizures, anticholinergic effects, antihistaminic effects, & neuroleptic malignant syndrome.
    • Links:
      • A short story about three genetic studies believed to show possible causes for Schizophrenia.
        • Possible Causes for Schizophrenia
        • "Schizophrenia May Be Linked To Immune System." All Things Considered. National Public Radio. July 1, 200
        • An interview with Patrick Tracey, who traced his family's history with Schizophrenia back five generations
        • Family's History with Schizophrenia
        • "Tracing the Roots of 'Irish Madness'." Talk of the Nation. National Public Radio. Aug. 28, 2008
      • A case study in schizophrenia
      • Radio contributor Scott Carrier tells the story of a job he had at a particularly bleak point in his life, interviewing people diagnosed with Schizophrenia. Story begins at minute 3, and ends at minute 18:30.
  • Articles:
    • New hope for people with schizophrenia
    • A recipe for schizophrenia symptoms?
    • Murry (1943) also provided a psychological evaluation of Hitler for the Office of Strategic Services. He believed that Hitler showed signs of schizophrenia paranoid type. Along with Schizophrenia he believed that Hitler exhibited signs of panic attacks, irrational jealousy, and delusions of persecution, omnipotence, megalomania, and ‘messiah ship’. He is one of the many theorist who believe that these psychopathic symptoms derived from his stay at Pasewalk. He noted that Hitler was able to gain control over his hysterical and paranoia. He used them to enhance his own standing by inflaming the nationalistic passions of the German people and fan hatred. (Murry, H. A. (1943). Analysis of the personality of Adolf Hitler with prediction of his future behavior and suggestion for dealing with him now and after Germany’s surrender. A report prepared for the Office of Strategic Services, October, 1943. Retrieved from www.lawschool.cornell.edu/library/donovan/hitler. )
    • Coolidge, Davis, and Segal (2007) did an experiment in which they had five academic historians, with 10 years of hitlerian studies, current or former university faculty appointment, and a published book or article about hitler or Nazi Germany, completed the CATI of Hitler. They found that Hitler would have most likely been diagnosed with schizophrenia paranoid type. The mean consensus T score for schizophrenia scale was almost two standard deviations above the normal mean. His scoring on the Psychotic Thinking and Paranoid scales also support this diagnosis. The researchers also found high scores for PTSD. He was three standard deviations above the normal mean.(Coolidge, F. L., Davis, F. L., & Segal, D. L. (2007). Understanding madmen: A DSM-IV assessment of Adolf Hitler. Individual Differences Research, 5(1), pp. 30-43.)

  • A Beautiful Mind is a 2001 movie about a man who develops paranoid schizophrenia and experiences delusional episodes.


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3. Schizophrenia, Disorganized Type (295.10)


This video depicts a man, Peter, who is suffering from Schizophrenia, Disorganized Type



    • DSM-IV-TR criteria
      • Schizophrenia in which the following criteria are meet:
      • All of the following are prominent for a diagnosis to be made:
        1. Disorganized speech
        2. Disorganized behavior
        3. Flat or inappropriate affect
      • The criteria are not met for Catatonic Type
    • Associated features
      • The essential features of the Disorganized Type of Schizophrenia are:
        • Disorganized speech, disorganized behavior, and flat or inappropriate affect.
        Having disorganized speech may be accompanied by madness and laughter that are not closely related to the content of the speech.
        The behavioral disorganization (i.e., the lack of goal orientation) may lead to severe disruption in the ability to perform activities of daily living (i.e., showering, dressing, or preparing meals).
        Those individuals suffering from the Disorganized Type of schizophrenia may also demonstrate improper "normal behaviors" including masturbating or defecating in public.
        Criteria for the Catatonic Type of Schizophrenia are not met, and delusions or hallucinations, if present, are fragmentary and not organized into a coherent theme. Associated features include grimacing, mannerisms, and other oddities of behavior. Impaired performance may be noted on a variety of neuropsychological and cognitive test.
        This subtype is also usually associated with poor pre-morbid personality, early and insidious onset, and a continuous course without significant remissions.
        Historically, and in other classification systems, this type is termed hebephrenic, which is characterized by foolish mannerisms, senseless laughter, delusions, hallucinations, and regressive behavior.
      • Individuals with Disorganized Type of Schizophrenia might suffer from social deficits, which is an impaired ability to understand and solve social problems. They behave "silly" or seem weird to most people. For example, individuals suffering from Disorganized type laugh or giggle at inappropriate times.
      • Individuals might also suffer from emotional deficits, which some Schizophrenics might show abnormal expressions of emotions, or an impaired ability to recognize emotion in others. Sufferers of Disorganized type schizophrenia also have problems showing the correct emotion for example they might be the ones to laugh at a funeral.
      • Substance abuse is very prevalent in Schizophrenia cases. 80-90% use nicotine heavily. In many cases many are polysubstance abusers.
      • Most Schizophrenics are at a high suicide risk. (10% succeed)
      • Also if these individuals display hallucinations and delusions, their behavior tends to be bizzare and poorly organized.
      • Individuals do not respond well to treatment.
    • Child vs. adult presentation
      • In recent research it has been shown that signs of schizophrenia may be present before clincal symptoms of psychosis appear. Normally schizophrenia develops in individuals sometime between adolescence and early adulthood. During childhood, symptoms can be minimal and discrete, however through adolescence and into adulthood these symptoms will gradually increase in number and severity. It is extremely rare for the onset of schizophrenia to occur before adolescence (before the age of 12). Studies suggest that adult onset schizophrenia and childhood development of the disorder both lead to similar, if not identical, symptoms and complications. The life of the symptoms reported is similar to that seen in adult cases with the predictable developmental variations. For example, delusions are less complex in children and reflect childhood themes.
    • Gender and cultural differences in presentation
      • Women often have a milder overall course and later onset of schizophrenia than men. Men are more likely to receive treatment for the disorder. Some research suggests that social skills training may be more helpful to men than to women. Because treatment studies usually sample persons with schizophrenia who are currently receiving treatment it leads to more information gathered on males than in females. The prevalence of schizophrenia is comparable across different cultures. Several studies have shown that the course of the illness is more benevolent in developing countries compared to industrialized nations. Certain cultural interpretations of schizophrenia may promote more acceptance of people who display the symptoms. Without a clear understanding of the religious and cultural background, patients may be misdiagnosed. Knowledge of cultural norms appears critical to avoid the possible misinterpretation of culturally bound beliefs, experiences, and practices when arriving at a diagnosis. Stigma also plays an important role for cultural factors; this can greatly undermine the person’s ability to recover from the effects of schizophrenia. Also, this can cause difficulties in integrating into society.
    • Epidemiology
      • It is estimated that approximately 2.2 million persons in the United States have Schizophrenia at any given time.
      • The annual incident rate of new cases of Schizophrenia has ranged from 16 to 40 per 100,000 persons.
      • One- year prevalence rates of Schizophrenia have ranged from 1% to 4.6% per 1,000 persons.
      • The lifetime prevalence of Schizophrenia lies between 0.55% and 1% per 100 persons worldwide.
      • The prevalence is believed to be remarkably stable across a wide range of: different populations, cultures, genders, races, and religions.
      • People with the illness are especially affected in that they are less likely to marry or remain married, particularly males.
      • Also people with Schizophrenia are less likely to complete higher levels of education.
      • Only 14% to 20% of persons with Schizophrenia hold competitive employment.
    • Etiology
      • Studies that have been done in the past 30 years are indicating that the risk of developing Schizophrenia in biological relatives of persons with Schizophrenia is greater than in the general population, even in the absence of any contact between relatives.
        The odds of developing Schizophrenia if one parent has the disorder is 13% and rises to 50% if both parents have the disorder, compared to only 1% risk in the general population.
      • The rate of one identical twin developing Schizophrenia if his or her twin also has Schizophrenia is between 25% and 50%, compared to about 6% and 15% for fraternal twins.
      • It also appears that the risk of developing Schizophrenia is greater in more severe types of Schizophrenia.
      • It is more likely that Schizophrenia is a polygenetic condition or arises from an interaction of multiple genes, which increase the receptiveness to the disorder. Chromosome 1 has been implicated in recent research (Hodge et al., 2009). Several studies have shown that single nucleotide polymorphisms associated with chromosome 1 are present in many varieties of schizophrenia. Future research conducted will need to focus on determining which single nucleotide polymorphisms in a person's DNA might alter genetic function and facilitate the development of schizophrenia.
    • Empirically supported treatments
      • Although no cures have been found yet for Schizophrenia, there are many treatment options to help a person with Schizophrenia cope with this disorder. Antipsychotic medication is the main biological treatment used in Schizophrenic cases. Antipsychotic medications block an excess of dopamine in the brain, but also effect other neurotransmitters as well as serotonin levels. Antipsychotic medications are usually grouped with psychosocial therapy treatments in order to treat the patient as effectively as possible. Although antipsychotic medications are useful, they can be dangerous and lead to major side effects.
      • Another treatment option is Psychosocial Therapy which includes family therapy, social skills training, and cognitive therapy. The most widely used type of therapy for schizophrenics is family therapy. In family therapy, the patient's family is educated about what is happening to their loved one and are taught ways to help communicate and deal with the situations that arise. Social skills training and Cognitive therapy are also popular ways in trying to treat schizophrenia. In social skills training, the patient is taught basic social skills such as maintaining eye contact and engaging in small talk to help build relationships with those around them. This type of therapy is helpful because Schizophrenics tend to push people away, and become isolated. This type of therapy can greatly help disorganized schizophrenics since they mostly struggle with showing emotions, as well as not knowing how to behave properly in public. Cognitive therapy is also a popular therapy choice in treating persons with Schizophrenia because it aims to reverse how they perceive themselves, others, and the world around them.


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4. Schizophrenia, Catatonic Type (295.20)


A Schizophrenic patient Hyde is catatonic, confined to a wheelchair and isolated. But Hyde is also imprisoned in his mind, tormented by grotesque hallucinations of his demonic doppelganger, Siek. Crippled by fear, Hyde is bound to a nightmare creature he can never kill in a place he can never escape.



    • DSM-IV-TR criteria
      • A type of Schizophrenia where the clinical picture is dominated by two of the following:
        1. Motor immobility as evidenced by catalepsy (including waxy flexibility) or stupor.
        2. Excessive motor activity that is purposeless and not influenced by external stimuli.
        3. Extreme negativism or mutism.
        4. Peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing.
        5. Echolalia or echopraxia
    • Associated features
      • Those diagnosed with the Catatonic subtype of schizophrenia are characterized by extreme psychomotor dysfunctions. They experience physical immobility; this occurs when they are completely unable to move or speak.
      • They also may go into a catatonic stupor, which includes a form of waxy flexibility. Waxy flexibility occurs when a patients arm is moved into a position and remains in that position for hours.
      • A catatonic Schizophrenic may also experience fits of excessive movement or mobility. These movements seem to have no purpose; it could include pacing, turning in circles, flailing of the arms, or making loud noises.
      • Another feature of catatonic Schizophrenia is extreme negativism or mutism. This is when the person exhibits extreme resistance to instructions or help. They will resist any attempt to be moved and may refuse to speak.
      • Peculiar postures or movements are also common with Catatonic Schizophrenia. This includes things such as posturing, which is sitting odd or bizarre postures for long periods of time. This could also include grimacing or the adoption of odd mannerisms.
      • Along with fore mentioned symptoms, stereotyped behaviors are common, such as repeating words, following a routine obsessively, or constantly arranging objects the same way.
      • Catatonic Schizophrenics will often suffer from echolalia, which causes them to involuntarily repeat things that they hear. They also suffer from echopraxia, which is the involuntary copy of movements or gestures made by someone else.
      • Some other symptoms along with the catatonic behaviors could include delusions, hallucinations, incoherent speech, angry outbursts, neglect of personal hygiene, social isolation, and clumsy, uncoordinated movements.
      • Other associated symptoms would include cognitive deficits, such as difficulty with the processing of visual stimuli because they can only focus on one object, poor verbal and spatial memory, abstract reasoning, poor psycho motor speed, and very poor planning ability.
      • Social and emotional deficits are also seen. There is an impaired ability to solve or understand social problems and issues. They have an impaired ability to recognize emotion expressed in others and also have an abnormal expression of emotions. For example, they do not always respond with the correct emotion, such as being happy when they should be sad.
      • There are high rates of substance abuse seen. Around 80-90% use nicotine heavily and many use more than one substance, such as alcohol and nicotine.
      • There are also high rates of attempted suicide. About 50-70% of schizophrenics attempt suicide and 10% succeed.
    • Child vs. adult presentation
      • A very small number of Schizophrenics experience childhood onset. The DSM IV-TR uses the same criteria to diagnose children as it does adults. The treatments for children are very similar to the ones that are used on adults, but in children one must be very careful with the drug treatments because there is little data on the long-term outcomes of anti-psychotics on children. Children who have a schizophrenic onset will most likely have schizophrenia their entire life.
    • Gender and cultural differences in presentation
      • There does not seem to be much difference in schizophrenia across cultures. There is a slight difference between genders though, as slightly more males seem to have this disorder than females.
    • Epidemiology
      • The prevalence rate for catatonic schizophrenia is about 3% of those that are diagnosed with schizophrenia.
      • The prevalence rate for schizophrenia is about 1% of the general population.
      • Some psychologists would like to consider Catatonic Schizophrenia to be very rare now compared to what it was in the past. A Study done in Monroe County in New York from 1960 to 1967 proved otherwise. The researchers concluded, "The seven-year prevalence of catatonic schizophrenia, based on the span of this study, is close to one per 1,000 county inhabitants. Far from being a vanishing entity, the catatonic type of schizophrenia now represents five percent of all first diagnosis of schizophrenia."
    • Etiology
      • Although no one is exactly sure what causes schizophrenia it definitely has something to do with genes, but not entirely. Many theorize that certain genes give someone a predisposition to schizophrenia, but a mixture of genes and environmental factors play a role.
      • There is also the dopamine hypothesis. This theory suggests that a schizophrenic’s brain is producing too much dopamine at certain receptors, or that their receptors have become hypersensitive causing the dopamine neurons to fire off when they should not.
    • Empirically supported treatments
      • The main treatments used for catatonic schizophrenia include medications, electro-convulsive therapy, hospitalization, psychotherapy, or vocational skills training.
      • One medication available is Benzodiazepine. This sedative is usually the medication of choice for catatonic schizophrenia. It is usually injected into a vein, which is helpful if the patient is in a catatonic stupor, it is fast acting, and it helps to relieve the catatonic symptoms quickly. However, it may cause dependency over time.
      • There are also Barbiturates. These are also sedatives that have a similar effect. They work quickly and relieve the catatonic symptoms, but they are not often used to treat catatonic schizophrenia.
      • Antipsychotic medications, which are generally used with normal schizophrenia, are not recommended for those with catatonic type because they have a habit of make the catatonic symptoms worse.
      • Electroconvulsive therapy is when they shoot electric currents through a patient’s brain. This is only used when symptoms are extreme and medications are not effective.


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5. Schizoaffective Disorder (295.70)


    • DSM-IV-TR criteria
      • A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.
      • B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.
      • C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.
      • D. The disturbance is not due to the direct physiological effects of a substance (e.g., drug abuse, medication) or a general medical condition.
        • The bipolar type is diagnosed if the disturbance includes a manic or a mixed episode (or a manic or a mixed episode and major depressive episodes).
        • The depressive type is diagnosed if the disturbance includes only major depressive episodes.

      • Subtypes:
        • Bipolar Type (Schizomanic): if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes). Many but not all studies find that Schizomania is closer to Bipolar Disorder than to classic Schizophrenia. The family histories of Schizomanic patients are generally loaded with mood disorders and not with Schizophrenia. They frequently respond to mood stabilizers. Their prognosis is reasonably good—similar to that of Bipolar Disorder and not to Schizophrenia.
        • Depressive Type (Schizodepressive): if the disturbance only includes Major Depressive Episodes. Schizodepression is probably closer to classic Schizophrenia. Families of patients with Schizodepression show significant genetic loading for Schizophrenia and not as much for Bipolar Disorder; generally, these patients respond better to anti-psychotics than to mood stabilizers. Their prognosis is not as good as that of mood disordered patients and is much closer to that of Schizophrenic patients.
        • Chronic and Nonchronic forms: For Schizomania and Schizodepression, patients whose symptoms are more chronic and less episodic have worse prognoses.
    • Associated features
      • There may be poor occupational functioning, a restricted range of social contact, difficulties with self-care, and increased risk of suicide associated with Schizoaffective Disorder. Anosognosia (i.e., poor insight) is also common in Schizoaffective Disorder, and individuals with Schizoaffective Disorder may be at increased risk for later developing episodes of pure Mood Disorder, Schizophrenia, or Schizophreniform Disorder. There may be associated Alcohol and other Substance-Related Disorders.
      • Elevated risk for suicidal behavior among individuals with Schizoaffective Disorder is associated with history of suicidal behavior, severity of suicide ideation and fewer reasons for living, presence and severity of depression, long duration of untreated psychosis, number of hospitalizations in the prior 36 months, more frequent prescription of typical (vs. atypical) antipsychotic agents, and history of abuse or dependence on nicotine or other substances.
    • Child vs. adult presentation
      • Schizoaffective Disorder, Bipolar Type, may be more common in young adults, whereas Schizoaffective Disorder, Depressive Type, may be more common in older adults.
      • Schizoaffective Disorder usually starts in early adulthood.
      • Rarely is it diagnosed before age 13.
    • Gender and cultural differences in presentation
      • The incidence of Schizoaffective Disorder is higher in women than in men, which is mostly accounted for by an increased incidence among women of the Depressive Type.
      • Schizophrenic Disorders are more prevalent among individuals with lower Social Economic Status. The lower the SES, the more prevalent the Schizophrenic Disorders appear to be.
      • Little research has occurred examining which cultural factors, if any, both increase and decrease the risk of developing a Schizophrenic Disorder. Although, Schizophrenic Disorders appear to occur less often in what we consider to be third-world, or less industrially developed, countries.
    • Epidemiology
      • The prevalence rate for Schizoaffective disorder widely varies. Studies do show that Schizoaffective Manic patients appear to comprise 3-5% of psychiatric admissions to typical clinical centers.
    • Etiology
      • There is no single causal factor, a certain causal sequence of events, or one entity (genetic or otherwise) in the etiology of Schizoaffective Disorder. Although the exact etiology of Schizoaffective disorder is unknown, it may involve the balance of dopamine and serotonin in the brain. Others believe that it may be due to in-utero exposure to viruses, malnutrition, or even birth complications.
      • There is substantial evidence that there is an increased risk for Schizophrenia in first-degree biological relatives of individuals with Schizoaffective Disorder. Most studies show that relatives of individuals with Schizoaffective Disorder are at increased risk for Mood Disorders. As a group, Schizoaffective patients have family histories with increased genetic loading for both Schizophrenia and Mood Disorders.
      • The prognosis for Schizoaffective Disorder tends to be better than that for Schizophrenia and worse than that for Mood Disorders. The presence of precipitating events or stressors is associated with a better prognosis.
    • Differential Diagnosis
      • Substance-Induced Psychotic Disorder and Substance-Induced Delirium are distinguished from Schizoaffective Disorder by the fact that a substance is judged to be etiologically related to the symptoms.
      • Distinguishing Schizoaffective Disorder from Schizophrenia: In Schizoaffective Disorder, there must be a mood episode that is concurrent with the active-phase symptoms of Schizophrenia, mood symptoms must be present for a substantial portion of the total duration of the disturbance, and delusions or hallucinations must be present for at least 2 weeks in the absence of prominent mood symptoms. In contrast, mood symptoms in Schizophrenia have a duration that is brief, occur only during the prodromal or residual phases, or do not meet full criteria for a mood episode.
      • Distinguishing Schizoaffective Disorder from Mood Disorder with Psychotic Features: If psychotic symptoms occur exclusively during periods of mood disturbance, the diagnosis is Mood Disorder with Psychotic Features. In Schizoaffective Disorder, symptoms should not be counted toward a mood episode if they are clearly the result of symptoms of Schizophrenia. Criterion A for Schizoaffective Disorder, the Major Depressive Episode must include pervasive depressed mood.
      • Mood disturbances, especially depression, commonly develop during the course of Delusional Disorder. However, such presentations do not meet criteria for Schizoaffective Disorder because the psychotic symptoms in Delusional Disorder are restricted to non-bizarre delusions and therefore do not meet Criterion A for Schizoaffective Disorder.
      • Schizoaffective Disorder and Schizophrenia: because the relative proportion of mood to psychotic symptoms may change over the course of the disturbance, the appropriate diagnosis for an individual episode of illness may change from Schizoaffective Disorder to Schizophrenia. The diagnosis may also change for different episodes of illness separated by a period of recovery. If psychotic symptoms and affective symptoms always overlap, the person is diagnosed with an affective disorder, whereas if psychotic symptoms are present some of the time, in the absence of an affective syndrome, the person meets criteria for either Schizoaffective Disorder or Schizophrenia. Schizoaffective Disorder is diagnosed if the mood symptoms are prolonged
    • Empirically supported treatments
      • Schizoaffective patients respond better to lithium than do schizophrenics, but not as well as Bipolar patients.
      • Electroconvulsive therapy (ECT) is indicated for Schizoaffective disorder that has an acute onset, presence of hallucinations or delusions, and acute and severe mania, and that has been found to be non-responsive to psychotropic medications. However, some studies find that ECT is not productive in reducing hallucinations or delusions.
      • There is no cure for Schizoaffective Disorder. However, the most effective approach toward treating the Schizophrenic Disorders seems to be a combination of pharmaceutical, behavioral, cognitive, and family therapy, with the use of anti-psychotic medications seen as the primary treatment modality.
      • Pharmacotherapy with an antidepressant, an antipsychotic, and/or mood stabilizer is also a mainstream treatment. In quite a few instances, effective treatment modalities will work on attempting to rid the individual of hallucinations, delusions, and disorganized aspects of behavior, or at the very least, attempt to lessen these symptoms.
      • Even so, many individuals will relapse, even if their treatment is maintained.
      • Common medicines for neuroleptic symptoms are Olanzapine, Risperidone, Quetiapine, Aripiprazole, and Ziprasidone. Mood stabilizer medications examples are Lithium salt, Valproate semisodium, and Carbamazepine.

  • Links
-- Living with Schizoeffective disorder. See video http://www.youtube.com/watch?v=lwKGe-Si1jo

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6. Brief Psychotic Disorder (298.8)

    • DSM-IV-TR criteria
      • A. Presence of one or more of the following:
        1. Delusions
        2. Hallucinations,
        3. Disorganized speech (e.g., frequent derailment or incoherence)
        4. Grossly disorganized or catatonic behavior
        • NOTE:* You should not include these symptoms if they are a culturally sanctioned response pattern.
      • 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 accounted for by a Mood Disorder With Psychotic Features, Schizoaffective Disorder, or Schizophrenia and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition
      • Specify if:
        • With Marked Stressor(s) (brief reactive psychosis): if symptoms occur shortly after and in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture
        • Without marked Stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture
        • With Postpartum Onset: onset within 4 weeks postpartum
    • Associated features
      • People with brief psychotic disorder usually experience emotional problems as well as huge amounts of confusion. They usually experience dramatic shifts of intense mood.
      • The level of impairment for this disorder may be brief, but it could also be very severe. The individual needs to be protected from the consequences of cognitive impairment, acting on the basis of delusions, and poor judgment. Because of this, supervision may be required. Also, supervision is needed in order to make sure that nutritional and hygienic needs are met and kept.
      • There is a high risk of suicide among younger teens who have this psychotic disorder and a highly increased risk of mortality among them also.
      • Personality disorders such as paranoid, schizotypal, and borderline personality disorder, along with others, may increase the development of brief psychotic disorder.
      • People who suffer from this disorder often have just lost a loved one or recently experience some form of intense grief. Afterward, they might experience extreme symptoms such as hallucinations or delusions, memory loss/impairment, confusion, and other physical changes (sleeping and eating patterns etc.).
    • Child vs. adult presentation
      • Brief psychotic disorder is very rarely seen in children. On average, it usually appears more in adolescence or early adulthood. The age of onset is usually around late 20’s to early 30’s.
    • Gender and cultural differences in presentation
      • Gender differences in brief psychotic disorder are rarely seen. There is, however, some evidence of a slightly higher rate of brief psychotic disorder in women than men.
      • Cultural differences, on the other hand, are very popular. For example, if a patient reported hearing voices in the United States, they may be put on medications for brief psychotic disorder. In other cultures, however, if a patient hears voices it could be seen as a normal thing. It is part of their culture and their community as a whole may be experiencing the same phenomenon.
    • Epidemiology
      • The epidemiology is usually considered uncommon. The exact prevalence, and/or incidence is not fully known, therefore making the cause of brief psychotic disorder a mystery as of right now.
    • Etiology
      • The cause of brief psychotic disorder, as stated earlier, is unknown. People who have this disorder may have a psychological or even a biological vulnerability to developing the disorder or simply the symptoms of the disorder. Having other psychotic disorders makes the patient more prone to develop brief psychotic disorder.
    • Empirically supported treatments
      • If the symptoms are severe, a person may be admitted into a hospital to try and treat brief psychotic disorder. Other than this, psychotherapy and medications are used often. Psychotherapy is a method used to help the patient deal with, or cope with the disorder and learn how to handle the stressor that signaled it. The medications that are given to the patients are called anti-psychotic drugs. The anti-psychotic drugs help decrease the symptoms of brief psychotic disorder and also may eliminate the symptoms.
      • A few common medications used are Thorazine, Prolixin, Haldol, and Trilafon.The prognosis becomes better the soon the disorder is diagnosed and treatment can begin.
      • There is no known way to prevent this disorder.
  • A Man who Suffered from Brief Psychotic Disorder, but had a postive recovery



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7. Delusional Disorder (297.1)


    • DSM-IV-TR criteria
      • A. Non-bizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration.
      • Symptoms include:Nonbizarre delusions for at least one month.
      external image bullet_grey.gif Absence of obviously odd or bizarre behavior.
      external image bullet_grey.gif Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out.
      external image bullet_grey.gif Absence of evidence that an organic factor initiated and maintained this psychotic disturbance.
      external image bullet_grey.gif Absence of prominent hallucinations of a voice for at least one week. Absence of visual hallucinations for at least one week.
      external image bullet_grey.gif Has never met the criteria for the active phase of Schizophrenia.
      Subtypes
      • B. Criterion A for Schizophrenia has never been met.
        • *Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme.
      • C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
      • D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.
      • E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
    • Specify type (the following types are assigned based on the predominant delusional theme):
      • 1. Erotomanic Type: delusions that another person, usually of higher status, is in love with the individual.
      • 2. Grandiose Type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.
      • 3. Jealous Type: delusions that the individual's sexual partner is unfaithful.
      • 4. Persecutory Type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way.
      • 5. Somatic Type: delusions that the person has some physical defect or general medical condition.
      • 6. Mixed Type: delusions characteristic of more than one of the above types but no one theme predominates.
      • 7. Unspecified Type
    • Associated features
      • People with Delusional Disorder often appear to be very “normal” and function in many areas of their life without any difficulty. Others such as family members, coworkers, or doctors are more likely to see a problem than the person themselves.
      • The person with Delusional Disorder may develop a particular mood in reaction to their delusion, such as gloomy, irritated, extreme anger, or violence. One may go for unnecessary medical tests on a regular basis.
      • According to Kendler and Manschreck, associated factors include being married, being employed, recent immigration, low socioeconomic status, celibacy among men, and widowhood among women (Kendler, 1982; Manschreck, 2000).
    • Child vs. adult presentation
      • The onset of this disorder ranges from adolescents to adulthood but appears more frequently later in life.
      • The age of onset ranges from 18 to 90 and the mean onset is around 40.
    • Gender and cultural differences in presentation
      • There is no specific culture that presents with Delusional Disorder more than any other culture.
      • Overall, there are no obvious gender differences with Delusional Disorder.
      • The ratio for males to females with the disorder is about 1:1; however, some delusion types such as Jealous Type can be seen more commonly in men than in women.
      • Typically, there is an excess of women with the disorder.
    • Epidemiology
      • An uncommon disorder, the prevalence of delusional disorder in the United States is estimated in the DSM-IV-TR to be around 0.03%.
      • The age of onset can range anywhere from 18-90 years, with an average of about 40 years.
    • Etiology
      • Many factors seem to play a part in the etiology of this disorder, but a clear etiology is unknown. Because it is generally difficult to diagnose this disorder and those with this disorder to not often seek treatment, the etiology has not been extensively studied.
      • However, there are several theories as to what causes this disorder including genetic/biological factors, cognitive processing errors, or defensive delusions.
      • In studies that have been conducted, it has been shown that those persons with relatives with delusional disorder have higher rates of the disorder, suggesting that a genetic factor might play a part.
      • Additionally, persons with this disorder may have distorted views of people and life, which can lead to delusional interpretations of daily events.
    • Empirically supported treatments
      • Treatment for Delusional Disorder often involves both biological therapy, such as medications, as well as psychotherapy.
      • Medicinal treatments may involve anti-psychotics and antidepressants such as SSRI and Clomipramine. Agitation, a state of frantic activity experienced with anger or fearfulness can occur from some of these medications. When this situation occurs, haloperidol can be given.
      • Psychotherapy treatments involve supportive therapy and cognitive therapy.
      • Treatment should be explored and implemented on a case by case basis, as each client is unique and needs an individualized treatment. Combining the medications with cognitive therapy is generally the best solution.
      Links:
    • What is Delusional Disorder?



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8. Shared Psychotic Disorder (273.5)


    • DSM-IV-TR criteria
      • A delusion develops in an individual in the context of a close relationship with another person or persons, who have an already established delusion.
      • The delusion is similar in content to that of the person who already has an established delusion.
      • The disturbance is not better accounted for by another psychotic disorder (e.g., schizophrenia) or a mood disorder with psychotic features and is not due to the direct physiological effects of a substance (e.g., drug abuse, medication) or a general medical condition.
    • Associated features
      • Shared Psychotic Disorder is a rare condition where a healthy person, also known as secondary in this situation, shares the delusions and false beliefs that the other person refuses to give up.
      • Also, this usually occurs in the face of contradictory facts of a more superior person, also known as primary in this situation that has the psychotic disorder. Delusions may occur and may be similar to the ones experienced by someone close who has a psychotic disorder.
      • However, the primary individual with this disorder generally will have delusions less bizarre than an individual with schizophrenia and the delusions are much more believable, making it easier for the secondary individual to believe the delusion.
      • Individuals with Shared Psychotic Disorder do not usually have unusual or odd behavioral issues. Secondary hallucinatory experiences occur less frequently and are less intense than primary hallucinatory experiences.
      • In two reported cases, the secondary experienced hallucinations while the primary did not.
    • Child vs. adult presentation
      • Other than the fact that Shared Psychotic Disorder tends to occur in relationships that are time-honored and resistant to change, which could include children and adults, there is little information regarding child vs. adult presentation or onset.
    • Gender and cultural differences in presentation
      • Since the 1650s, Shared Psychotic Disorder has been identified more frequently in women, reflecting the traditional submissive role of females in the family. Nevertheless, no confirmation of increased susceptibility of females exists today.
      • Both female and male secondaries are equally affected by female primaries.
    • Epidemiology
      • Rarely seen in clinical settings, it is argued that some cases of Shared Psychotic Disorder go without ever being diagnosed. If it is brought to clinical attention, it is the result of the primary person receiving treatment. The person with Shared Psychotic Disorder does not walk into a clinic alone.
    • Etiology
      • The cause of Shared Psychotic Disorder is unknown. However, several possible factors are believed to play roles in the development of Shared Psychotic Disorder. Some researchers believe that the disorder comes from a psychosocial perspective, as most of the individuals with the disorder have immediate relatives with psychiatric disorders. Additionally, family isolation and the presence of a dominant-submissive factor within a relationship affect the presence of this disorder.
    • Empirically supported treatments
      • Effective treatment of the secondary requires neuroleptics and separation from the primary.
      • There are three possible treatments for Shared Psychotic Disorder: psychotherapy, family therapy, and medication.
        • Psychotherapy can help the person with Shared Psychotic Disorder recognize the delusion and correct the underlying thinking that has become distorted. It also can address relationship issues and any emotional effects of a short-term separation from the person with a psychotic disorder.
        • Family therapy might focus on increasing exposure to outside activities and interests, as well as the development of social supports to decrease isolation and help prevent relapse. Family therapy also might help to improve communication and family dynamics.
        • Short-term treatment with anti-psychotic medication might be used if the delusions do not resolve after separation from the primary case. In addition, tranquilizers or sedative agents such as lorazepam or diazepam (Valium) can help alleviate intense symptoms, such as anxiety, agitation, and insomnia, which might be associated with the disorder.
      • Individuals with this disorder rarely seek treatment, though, and are usually only brought to clinical attention when the primary case receives treatment.

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9. Schizophreniform Disorder (295.40)


    • DSM-IV-TR criteria
      • A. Criteria A, D, and E of Schizophrenia are met.
      • B. An episode of the disorder (including prodromal, active, and residual phases) 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.")
      • Specify if:
        • Without Good Prognostic Features - this is used if two of more of the features below have not been present.
        • With Good Prognostic Features: as evidenced by two (or more) of the following:
          (1) onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning.
          (2) confusion or perplexity at the height of the psychotic episode
          (3) good premorbid social and occupational functioning
          (4) absence of blunted or flat affect
    • Associated Features
      • Also see the discussion in the Associated Features and Disorders section for Schizophrenia, p.304. Unlike Schizophrenia, impairment in social or occupational functioning is not required for a diagnosis of Schizophreniform Disorder.
      • However, most individuals do experience dysfunction in various areas of daily functioning such as: learning problems, hypoactivity, euphoric mood, guilt or obsession, sexually deviant behavior, or even Dependent and Antisocial Personality Disorders.
    • Child vs Adult Presentation
      • Criteria of Schizophreniform Disorder in DSM is listed as "referrence to Schizophrenia".
      • Typically it is seen that this develops between the late teens and mid 30's.
      • It is very rare to see these disorders develop or be diagnosed in children; however there have been cases reported with the onset of 5 and 6.
      • It is also rare to see this develop in a later stage in life, but again there have been cases reported with the onset of 60 years. It is still unclear if identifiable brain pathology defines late-onset illness.
    • Gender and culture differences in presentation
      • For additional discussion of cultural, age, and gender factors relevant to the diagnosis of Schizophreniform Disorder, see the Specific Culture, Age, and Gender Features section for Schizophrenia (p306).
      • There are suggestions that in developing countries, recovery from Psychotic Disorders may be more rapid, which would result in higher rates of Schizophreniform Disorder than of Schizophrenia
    • Epidemiology
      • Available evidence suggests variations in incidence across sociocultural settings.
      • In the United States and other developed countries, the incidence is low, possibly fivefold less than that of Schizophrenia. In developing countries, the incidence is substantially higher, especially for the subtype "With Good Prognostic Features"; in some of these settings Schizophreniform Disorder may be as common as Schizophrenia.
      • There have been few studies of families where the focus has been Schizophreniform Disorder; however, there is available evidence that suggests that relatives of Schizophreniform Disorder have an increased risk for Schizophrenia.
    • Etiology
      • Approximately one-third of individuals with an initial diagnosis of Schizophreniform Disorder (Provisional) recover within the 6-month period and receive Schizophreniform Disorder as their final diagnosis of Schizophrenia or Schizoaffective Disorder.
      • The cause of it appears to be related to abnormalities in the structure and chemistry of the brain, and appears to have strong genetic links; but its course and severity can be altered by social factors such as stress or a lack of support within the family. It is less clear cut, but biological factors are also suspected
    • Empirically supported treatment
      • Treatment aims to protect and steady the patient, to minimize the psychosocial consequences, and to resolve the target symptoms with minimal adverse effects. The patient who may be at risk of harming himself, herself, or others requires hospitalization. This allows for complete diagnostic evaluation and helps to ensure the safety of the patient and others. A supportive environment with minimal stimulation is also helpful.
      • As improvement progresses, help with coping skills, problem-solving techniques, and psycho educational approaches may be added for patients and their families.
      • Patients may benefit from a structured intermediate environment, such as a day hospital, during the initial phases of returning to the community.
      • Pharmacotherapy for schizophreniform disorder is similar to that for schizophrenia. At this time, atypical antipsychotics, such as risperidone, olanzapine, quetiapine, and ziprasidone, are commonly used. In November 2003, a new atypical antipsychotic drug, aripiprazole (Abilify), was approved by the US Food and Drug Administration. Aripiprazole has a novel mechanism of action because it is a partial agonist at the dopamine receptors, unlike its predecessors.

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10. Psychotic Disorder Due to a General Medical Condition



    • DSM-IV-TR criteria
      • A. Prominent hallucinationations or delusions
      • B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
      • C. The disturbance is not better accounted for by another mental disorder
      • D. The disturbance does not occur exclusively during the course of a delirium
        • Code based on predominant symptom:
          • .81 With Delusions: if delusions are the predominant symptom
          • .82 With Hallucinations: if hallucinations are the predominant symptom
          • Coding note: Include the name of the general medical condition on Axis I, e.g., 293.81 Psychotic Disorder Due to Malignant Lung Neoplasm, With Delusions; also code the general medical condition on Axis III (see Appendix G for codes).
        • *Coding note: If delusions are part of vascular Dementia, indicate the delusions by coding the appropriate subtype, e.g., 290.42 Vascular Dementia, With Delusions.
    • Epidemiology
      • Prevalence rates for Psychotic Disorder Due to a General Medical Condition are difficult to estimate given the wide variety of underlying medical etiologies. Research does suggest that the syndrome is underdiagnosed in the general medical setting.
      • Psychotic symptoms may be present in as many as 20% of individuals presenting with untreated endocrine disorders, 15% of those with systemic lupus erythematosus, and up to 40% or more of individuals with temporal lobe epilepsy
    • Etiology
      • Psychotic Disorder Due to a General Medical Condition may be a single transient state or it may be recurrent, cycling with exacerbations and remissions of the underlying general medical condition.
      • Although treatment of the underlying general medical condition often results in a resolution of the psychotic symptoms, this is not always the case, and psychotic symptoms may persist long after the causative medical event )e.g., Psychotic Disorder Due to Focal Brain Injury).

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11. Substance-Induced Psychotic Disorder


    • DSM-IV-TR criteria
      • A. Prominent hallucinations or delusions. Note: Do not include hallucinations if the person has insight that they are substance induced.
      • B. There is evidence from the history, physical examination, or laboratory findings of either:
        • 1) the symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal
          or
        • 2) medication use of is etiologically related to the disturbance.
      • C. The disturbance is not better accounted for by a Psychotic Disorder that is not substance induced.
        Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use ( or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Psychotic Disorder (e.g., a history of recurrent non-substance-related episodes).
      • D. The disturbances do not occur exclusively during the course of a delirium.
    • *Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxicated or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.
    • Empirically supported Treatments
      • Once the person has become sober from their substance, the psychotic disorder disappears.
      • Drug therapy may be recommened due to the harmful effects of this disorder while intoxicated.
      • Behavioral therapy is recommended to help deal with underlying issues that play a role in the psychosis.


12. Psychotic Disorder Not Otherwise Specified


    • This category includes psychotic symptomatology (i.e., delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate information to make a specific diagnosis or about which there is contradictory information, or disorders with psychotic symptoms than do not meet the criteria for any specific Psychotic Disorder.
      • Examples include:
        • 1. Postpartum psychosis that does not meet criteria for Mood Disorder With Psychotic Features, Brief Psychotic Disorder, Psychotic Disorder Due to a General Medical Condition, or Substance-Induced Psychotic Disorder.
        • 2. Psychotic symptoms that have lasted for less than 1 month but that have not yet remitted, so that the criteria for Brief Psychotic Disorder are not met.
        • 3. Persistent auditory hallucinations in the absence of any other features
        • 4. Persistent nonbizarre delusions with periods of overlapping mood episodes that have been present for a substantial portion of the delusional disturbance
        • 5. Situations in which the clinician has concluded that a Psychotic Disorder is present, but is unable to determine whether it is primary, due to a general medical condition, or substance induced

13. Dementia of the Alzheimer's Type (294.1x)

    • DSM-IV-TR criteria
      • A. The development of multiple cognitive deficits manifested by both
        • 1) memory impairment (impaired ability to learn new information or to recall previously learned information)
        • 2) one (or more) of the following cognitive disturbances:
          • a) aphasia (language disturbance)
          • b) apraxia (impaired ability to carry out motor activities despite intact motor function)
          • c) agnosia (failure to recognize or identify objects despite intact sensory function)
          • d) disturbance in executive functioning (i.e. planning, organizing, sequencing, abstracting)
      • B. The cognitive deficits in Criterion A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
      • C. The course if characterized by gradual onset and continuing cognitive decline.
      • D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:
        • 1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hematoma, normal-pressure dydrocephalus, brain tumor)
        • 2) systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)
        • 3) substance-induced conditions
      • E. The deficits do not occur exclusively during the course of a delirium
      • F. The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Disorder, Schizophrenia
    • *Code based on presence or absence of a clinically significant behavioral disturbance:
      • 294.10 Without Behavioral Disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.
    • Gender and cultural differences in presentation
      • Alzheimer's is seen more in female patients than in males.
      • The onset of Alzheimer's before age 50 is rare in both sexes.
    • Associated Features
      • Individuals at risk and initial stages - Individuals with Down Syndrome and individuals with past head trauma are at a greater risk for developing Dementia of the Alzheimer's Type.
      • Physiological precursors of Alzheimer's may be seen as early as the 40s, though recognizable symptoms do not present until later in life.
      • Associated laboratory findings - Not widely accepted, sensitive, and specific biological marker is currently available that is universally accepted as diagnostic of Dementia of the Alzheimer's Type in a living individual. In the majority of cases, brain atrophy in Dementia of the Alzheimer's Type, with wider corticalsulci and larger cerebral ventricles than would be expected given the normal aging process. This may be demonstrated by computed tomography (CT) or magnetic resonance imaging (MRI). Microscopic examination usually reveals histopathological changes, including senile plaques, neurofibrillary tangles, granulovascular degeneration, neuronal loss, astrocytic gliosis, and amyloid angiopathy. Lewy bodies are sometimes seen in the cortical neurons.
      • Associated physical examination findings and general medical conditions - In the first years of illness, few motor and sensory signs are associated with Dementia of the Alzheimer's Type. Later in the course, myoclonus and gait disorder may appear.
      • Seizures occur in approximately 10% of individuals with the disorder
    • Epidemiology
      • The prevalence of Dementia of the Alzheimer's Type increases dramatically with increasing age, rising from 0.6% in males and 0.8% in females at age 65 (all levels of severity) to 11% in males and 14% in females at age 85.
      • At age 90 the prevalence rises to 21% in males and 25% in females, and by age 95 the prevalence is 36% in males and 41% in females.
      • Moderate to severe cases make up about 40%-60% of these estimated prevalence rates
    • Etiology
      • Dementia of the Alzheimer's Type is chronic and degenerative.
      • In many cases, initial deficits in working memory are followed by aphasia, apraxia, and agnosia. Coinciding with these physiological changes are behavioral changes; individuals may become increasingly more irritable and, in some cases, territorial. Familiar surroundings will become unfamiliar; if home remodeling has been done in the past several years, individuals with Dementia of the Alzheimer's Type may begin to perceive their homes as more and more foreign.
      • In the more advanced stages, individuals will develop motor disturbances and will eventually may become fully incapacitated.
      • Average life expectancy from the onset of Dementia of the Alzheimer's Type to its conclusion in death is approximately 8-10 years.

      • Link to Diabetes - While research has failed to demonstrate conclusively any causal relationship between Dementia of the Alzheimer's Type and Diabetes, it is been established that Diabetes and Alzheimer's are highly correlated. Individuals with Diabetes are at a severe risk when comorbid Alzheimer's is present. Individuals with Diabetes often must have extremities amputated due to infection, and if said individuals have Alzheimer's and cannot remember that these extremities have been lost, there can be dire consequences (e.g. serious falls).
    • Empirically supported treatments
      • Supported treatments include caregiving and pharmacotherapy.

Relearning face-name associations in early Alzheimer's Disease


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14. Vascular Dementia (formerly Multi-Infarct Dementia) (290.4x)


    • DSM-IV-TR criteria
      • A. The development of multi cognitive deficits manifested by both:
        • 1) memory impairment (impaired ability to learn new information or to recall previously learned information)
        • 2) one (or more) of the following cognitive disturbances:
          • (a) Aphasia- (language disturbance)
          • (b) Apraxia- (impaired ability to carry out motor activities despite intact motor function)
          • (c) Agnosia- (failure to recognize or identify objects despite intact sensory function)
          • (d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

      • B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
      • C. Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reflexes, extensor plantar response, pseudobulbar palsy, gait abnormalities, weakness of an extremity) or laboratory evidence indicative of cerebrovascular disease (e.g., multiple infarctions involving cortex and underlying white matter) that are judged to be etiologically related to the disturbance.
      • D. The deficits do not occur exclusively during the course of a delirium
    • Code based on predominant features:
      • 290.41 With Delirium: if delirium is superimposed on the dementia
      • 290.42 With Delusions: if delusions are the predominant feature
      • 290.43 With Depressed Mood: if depressed mood (including presentations that meet full symptom criteria for a Major Depressive Episode) is the predominant feature. A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given.
      • 290.40 Uncomplicated: if none of the above predominates in the current clinical presentation

    • Specify if:
      With Behavioral Disturbance
      *Coding note: Also cerebrovascular condition on Axis III**

    • Associated Features
      • Associated descriptive features and mental disorders.
      • Associated laboratory findings. The extent of central nervous system lesions detected by CT and MRI in Vascular Dementia typically exceeds in the extent of changes detected in the brains of healthy elderly persons (e.g., periventricular and white matter hyperintensities noted on MRI scans). Lesions often appear in both white matter and gray matter structures, including subcortical regions and nuclei. Evidence of old infarctions (e.g., focal atrophy) may be detected, as well as findings of more recent laboratory evidence of associated cardiac and systemic vascular conditions (e.g., ECG abnormalities, laboratory evidence of renal failure).
      • Associated physical examination findings and general medical conditions. Common neurological signs (e.g., abnormal reflexes, weakness of an extremity, gait disturbance) are discussed in the "Diagnostic Features" section. There is often evidence of long-standing arterial hypertension (e.g., funduscopic abnormalities, enlarged heart), valvular heart disease (e.g., abnormal heart sounds), or extracranial vascular disease that may be sources of cerebral emboli. A single stroke may cause a relatively circumscribed change in mental state (e.g., an aphasia following damage to the left hemisphere, or an amnestic disorder from infarction in the distribution of the posterior cerebral arteries), but generally does not cause Vascular Dementia, which typically results from the occurrence of multiple strokes, usually in different times
    • Gender and cultural differences in presentation
      • In most countries, vascular dementia is a much less common form of dementia than AD.
      • This is true in North America and Europe, but is not so in Japan, where it is more common than AD. Overall, vascular dementia is the second most common form of dementia, after AD.
      • About 10–20% of patients who experience dementia have the vascular form of the disorder.
      • The difference in prevalence in different countries may result from different lifestyle factors rooted in the culture
      • Vascular dementia is more common in men than in women, which may be because men are more likely than women to suffer from strokes.
      • Vascular dementia becomes increasingly prevalent as people grow older.
      • The number of people affected by vascular dementia rises dramatically during and after the sixth decade. Vascular dementia usually occurs at a younger age than AD.
      • The onset of Vascular Dementia is typically earlier than that of Dementia of the Alzheimer's Type.
    • Epidemiology
      • Vascular Dementia is reportedly much less common than Dementia of the Alzheimer's Type
    • Etiology
      • See p. 152 for a general discussion of the course of dementia.
      • The onset of Vascular Dementia of typically abrupt, followed by a stepwise and fluctuating course that is characterized by rapid changes in functioning rather than slow progression.
      • The course, however, may be highly variable, and an insidious onset with gradual decline is also encountered. Usually the pattern if deficits is "patchy," depending on which regions of the brain have been destroyed.
      • Certain cognitive functions may be affected early, whereas others remain relatively unimpaired.
      • Early treatment of hypertension and vascular disease may prevent further progression.


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15. Schizophrenia Residual Type

Features:
    • Residual-type schizophrenia is characterized by a past history of a least one episode of schizophrenia, but the person will currently have no positive symptoms (delusions, hallucinations, disorganized speech or behavior). Symptoms may represent a transition between a full-blown episode and complete remission, or it may continue for years without any further psychotic episodes.
    • DSM criteria
      • A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.
      • B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
      • Residual schizophrenia is typically by diagnosed by the following symptoms:
        • a. Prominent “negative” schizophrenic symptoms, such as psychomotor slowing, underactivity, blunting of affect, passivity and lack of initiative, poverty of quantity or content of speech, poor nonverbal communication by facial expression, eye contact, voice modulation, and posture, poor self-care and social performance
        • b. Evidence in the past of at least one psychotic episode meeting the diagnostic criteria for schizophrenia;
        • c. A period of at least 1 year during which the intensity and frequency of florid symptoms such as delusions and hallucinations have been minimal or substantially reduced and the “negative” schizophrenic syndrome has been present;
        • d. Absence of dementia or other organic brain disease or disorder, and of chronic depression or institutionalism sufficient to explain the negative impairments.

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16. Schizophrenia Undifferentiated Type


    • DSM criteria:
      • A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.
        • Criterion A
          • delusions
          • hallucinations
          • disorganized speech (e.g., frequent derailment or incoherence)
          • grossly disorganized or catatonic behavior
          • negative symptoms (e.g., affective flattening, alogia, or avolition)
  • * Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.
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