Schizophrenia Spectrum and other Disorders

 

What is a schizophrenic disorder? 

Schizophrenia is a startling disorder characterized by a broad spectrum of cognitive and emotional dysfunction including delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms. 

Many psychologists have tried to diagnose schizophrenia like-

1809    John Haslem         Portrayed schizophrenia as a form of insanity. 

1809    Philippe Pinel       Described people having schizophrenia 

1859    Benedict Morel     Used demence (loss of mind) precoce (early, premature) because of early                                                  onset of this disorder.    

1899    Emil Kraeplin       Presented most enduring description and categorization of schizophrenia                                                  (Dementia praecox)

1908    Eugen Bleuler       Introduced the term Schizophrenia

Schizophrenia which comes from the combination of Greek words for 'split' (skhizein) and 'mind' (phren), reflected Bleuler's belief that underlying all the unusual behaviors shown by people with this disorder was an associative splitting of the basic functions of personality. 

Key features that define the psychotic disorders:

Psychotic behaviors are unusual behaviors, although in its strictest sense, it usually involves delusions and/or hallucinations. 

POSITIVE SYMPTOMS

Obvious signs of psychosis, experienced by 50-70% of people with schizophrenia. 

Delusions:

A belief that would be seen by most members of a society as a misinterpretation of reality is called a disorder of thought content or delusion. It is a fixed belief which is not amenable to change in light of conflicting evidence. It is the BASIC characteristic of schizophrenia.  

• Persecutory delusions: (most common) belief that one is going to be harmed, harassed, and so forth by an individual, organization or other groups. 
• Referential delusions: belief that certain gestures, comments, environmental cues and so forth are directed at oneself.
• Grandiose delusions: when an individual believes he/she has exceptional abilities, wealth or fame. 
• Erotomanic delusions: when an individual beliefs falsely that the other person is in love with him/her. 
• Nihilistic delusions: involves the conviction that a major catastrophe will occur.
• Somatic delusion: focus on preoccupations regarding health and organ function. 

Delusions that express a loss of control over mind or body are generally considered to be bizarre; these include:

• Thought withdrawal- the belief that one's thoughts have been "removed" by some outside force 
• Thought insertion- that alien thoughts have been put into one's mind or 
• Delusions of control- that one's body or actions are being acted on or manipulated by some outside force. 
• Capgras Syndrome- the person believes someone he or she knows has been replaced by a double.
• Cotard's Syndrome- a person believes he/she is dead. 

Theories that explain the reasons for delusion-

1. Motivational theory- looks at these beliefs as attempts to deal with and relieve anxiety or stress. 
2. Deficit theory- these beliefs are a result of brain dysfunction that creates these disordered cognitions or perceptions.  

Hallucinations:

Hallucinations are perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control. 

• Auditory hallucinations are usually experienced as voices, whether familiar or unfamiliar, that are perceived as distinct from the individual's own thoughts (most common). 

DISORGANIZED SYMPTOMS

These include a variety of erratic behaviors that affect speech, motor behavior, and emotional reactions. The prevalence is unclear. 

Disorganized Thinking (Speech):

The individual may switch from one topic to another (derailment or loose associations). Answers to questions may be obliquely related or completely unrelated (tangentiality). 

Grossly disorganized or abnormal motor behavior:

Grossly disorganized or abnormal motor behavior may manifest itself in a variety of ways, ranging from childlike "silliness" to unpredictable agitation. Sometimes they exhibit bizarre behaviors such as hoarding objects or acting in unusual ways in public, laughing or crying at improper times. Problems may be noted in any form of goal-directed behavior, leading to difficulties in performing activities of daily living. 

Catatonic behavior: 

Catatonic behavior is a marked decrease in reactivity to the environment. This ranges from resistance to instructions (negativism); to maintaining a rigid, inappropriate or bizarre posture; to a complete lack of verbal and motor responses (mutism and stupor). It can also include purposeless and excessive motor activity without obvious cause (catatonic excitement). Other features are repeated stereotyped movements, staring, grimacing. mutism, and the echoing of speech.

NEGATIVE SYMPTOMS

It indicates the absence or insufficiency of normal behavior. 

 

Diminished emotional expression/ Affective Flattening 

It includes reductions in the expression of emotions in the face, eye contact, intonation of speech (prosody), and movements of the hand, head, and face that normally give an emotional emphasis to speech. 

Avolition

A meaning 'without' and volition, which means 'an act of choosing, willing or deciding'. It is a decrease in motivated self-initiated purposeful activities. The individual may sit for long periods of time and show little interest in participating in work or social activities, even the most basic day-to-day functions including those associated with personal hygiene. .

Alogia

A meaning 'without' and logos meaning 'words', Alogia means relative absence of speech. It takes the form of brief replies that have little content or delayed comments or slow responses to questions. 

Anhedonia

A meaning 'without' and hedonic meaning 'pertaining to pleasure', Anhedonia is a presumed lack of pleasure experienced by some people with schizophrenia. It signals an indifference to activities that would typically be considered pleasurable. 

Asociality 

A meaning 'without' and social meaning 'relating to society or its organization', Asociality refers to the apparent lack of interest in social interactions and may be associated with avolition, but it can also be a manifestation of limited opportunities for social interactions.

Below you will find a list of different Schizophrenic Disorders:

1. Schizotypal (Personality) Disorder

Diagnostic Criteria:

A. The presence of one (or more) delusions with a duration of 1 month or longer.

B. Criterion A for schizophrenia has never been met.

    Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).

C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.

D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. 

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.

    Specify whether:

• Erotomanic type: This subtype applies when the central theme of the delusion is that another person is in love with the individual.
• Grandiose type: This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery.
• Jealous type: This subtype applies when the central theme of the individual's delusion is that his or her spouse or lover is unfaithful.
• Persecutory type: This subtype applies when the central theme of the delusion involves the individual's belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.
• Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations.
• Mixed type: This subtype applies when no one delusional theme predominates.
• Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component).

    Specify if:

    With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not understandable, and not derived from ordinary life experiences (e.g., an individual's belief that a stranger has removed his or her internal organs and replaced them with someone else's organs without leaving any wounds or scars).

    Specify if:

    The following course specifiers are only to be used after a 1-year duration of the disorder:

• First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
• First episode, currently in partial remission: Partial remission is a time period during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
• First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
• Multiple episodes, currently in acute episode episodes, currently in partial remission
• Multiple Multiple episodes, currently in full remission
• Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
• Unspecified

    Specify current severity:

    Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe).

    Note: Diagnosis of delusional disorder can be made without using this severity specifier.

Diagnostic features: 

1. Individuals may be able to factually describe that others view their beliefs as irrational but are unable to accept it themselves. 

2. Many individuals may develop irritable or dysphoric mood. 

3. May engage in litigious or antagonistic behavior.

4. The assessment of cognition, depression and mania symptom domains is vital for making critically important distinctions. 

Prevalence:

Lifetime: 0.2% 

Most common- persecutory 

Most common in males- delusional disorder, jealous type. 

Development and Course:

More prevalent in older individuals but can also occur in younger age groups. 

2. Brief Psychotic Disorder

Diagnostic Criteria:

A. A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.

    Note: Do not include a symptom if it is a culturally sanctioned response.

B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning.

C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

    Specify if: With marked stressor(s) (brief reactive psychosis): If symptoms occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual's culture.

• Without marked stressor(s): If symptoms do not occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual's culture.
• With postpartum onset: If onset is during pregnancy or within 4 weeks postpartum.

    Specify if:

       With catatonia (refer to the criteria for catatonia associated with another mental dis- order, pp. 119-120, for definition)

Coding note: Use additional code 293.89 (F06.1) catatonia associated with brief psychotic disorder to indicate the presence of the comorbid catatonia.

        Specify current severity:

    Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor be- havior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chapter "Assessment Measures.")

    Note: Diagnosis of brief psychotic disorder can be made without using this severity specifier.

Diagnostic features: 

1. Individuals experience emotional turmoil or overwhelming confusion.  

2. Increased risk of suicidal behavior, particularly during the acute episode. 

3. Supervision is required. 

4. The assessment of cognition, depression and mania symptom domains is vital for making critically important distinctions. 

Prevalence:

US- 9%

More common- Developing countries

Two-fold more common in females than in males. 

Development and Course:

Age of onset- across lifetime

Average age of onset- mid-30s 

May appear in- adolescence, early adulthood.

Etiology:

Temperamental- Preexisting personality disorders and traits

3. Schizophreniform Disorder

Diagnostic Criteria:

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g.. frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition)

B. An episode of the disorder 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."

C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 

1. no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 
2. if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. 

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

    Specify if: With good prognostic features: This specifier requires the presence of at least two of the following features: onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; confusion or perplexity; good premorbid social and occupational functioning; and absence of blunted or flat affect. Without good prognostic features: This specifier is applied if two or more of the above features have not been present.

    Specify if: With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120, for definition).

    Coding note: Use additional code 293.89 (F06.1) catatonia associated with schizophreniform disorder to indicate the presence of the comorbid catatonia.

    Specify current severity:

    Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). 

    Note: Diagnosis of schizophreniform disorder can be made without using this severity specifier.

Prevalence:

More common- Developing countries

Etiology:

Genetic & Physiological- relative with schizophrenia 

4. Schizophrenia

Diagnostic Criteria:

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).

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

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that 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 by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

F. If there is a history of autism spectrum disorder or a communication disorder of child- hood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

    Specify if:

The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria.

• First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
• First episode, currently in partial remission: Partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
• First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
• Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).
• Multiple episodes, currently in partial remission
• Multiple episodes, currently in full remission
• Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
• Unspecified

    Specify if:

With catatonia 

Coding note: Use additional code 293.89 (F06.1) catatonia associated with schizophrenia to indicate the presence of the comorbid catatonia.

    Specify current severity:

    Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). 

    Note: Diagnosis of schizophrenia can be made without using this severity specifier.

Diagnostic features: 

1. Individuals who had been socially active may become withdrawn from previous routines. Such behaviors are often the first sign of a disorder.

2. Individuals with schizophrenia may display inappropriate affect (e.g., laughing in the absence of an appropriate stimulus); a dysphoric mood that can take the form of depression, anxiety, or anger; a disturbed sleep pattern (e.g., daytime sleeping and nighttime activity); and a lack of interest in eating or food refusal.

3. Cognitive deficits can include decrements in declarative memory, working memory, language function, and other executive functions, as well as slower processing speed.

4. Abnormalities in sensory processing and inhibitory capacity, as well as reductions in attention, are also found. 

5. Some individuals with schizophrenia show social cognition deficits, including deficits in the ability to infer the intentions of other people (theory of mind), and may attend to and then interpret irrelevant events or stimuli as meaningful, perhaps leading to the generation of explanatory delusions. 

6. Some individuals with psychosis may lack insight or awareness of their disorder (i.e., anosognosia). This lack of "insight" includes unawareness of symptoms of schizophrenia and may be present throughout the entire course of the illness.

7. Hostility and aggression can be associated with schizophrenia, although spontaneous or random assault is uncommon. Aggression is more frequent for younger males and for individuals with a past history of violence, non-adherence with treatment, substance abuse, and impulsivity.

Prevalence:

Lifetime: 0.3-0.7% 

More common in males- longer duration, negative symptoms

Development and Course:

Features appear in late teens and mid-30s

Onset prior to adolescence is rare. 

Peak age of onset- across lifetime

Average age of onset- mid-20s for males & late-20s for females

Etiology:

Environmental- season of birth (late winter/ early spring in some locations and summer for the deficit form of disease); higher in children growing up in urban environment.

Genetic & Physiological- pregnancy, birth complications with hypoxia; greater paternal age; prenatal and perinatal adversities like stress, infection, malnutrition, maternal diabetes, etc. 

5. Schizoaffective Disorder

Diagnostic Criteria:

A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1: Depressed mood.

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness. 

C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.

D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

    Specify whether

• 295.70 (F25.0) Bipolar type: This subtype applies if a manic episode is part of the presentation. Major depressive episodes may also occur.
• 295.70 (F25.1) Depressive type: This subtype applies if only major depressive episodes are part of the presentation.

    Specify if:

With catatonia (refer to the criteria for catatonia associated with another mental disorder. pp. 119-120, for definition).

Coding note: Use additional code 293.89 (F06.1) catatonia associated with schizoaffective disorder to indicate the presence of the comorbid catatonia.

    Specify it:

The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria. 

• First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled. 
• First episode, currently in partial remission: Partial remission is a time period during which an improvement after a previous episode is maintained and in which the de- fining criteria of the disorder are only partially fulfilled.
• First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
• Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).
• Multiple episodes, currently in partial remission
• Multiple episodes, currently in full remission
• Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
• Unspecified

    Specify current severity:

Severity is rated by a quantitative assessment of the primary symptoms of psychosis. including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). 

Note: Diagnosis of schizoaffective disorder can be made without using this severity specifier.

Diagnostic features: 

1. The diagnosis is usually, but not necessarily, made during the period of psychotic illness. 

2. Restricted social contact and difficulties with self-care are associated with schizoaffective disorder, but negative symptoms may be less severe and less persistent than those seen in schizophrenia. 

3. Anosognosia (i.e., poor insight) is also common in schizoaffective disorder, but the deficits in insight may be less severe and pervasive than those in schizophrenia. 

4. Individuals with schizoaffective disorder may be at increased risk for later developing episodes of major depressive disorder or bipolar disorder if mood symptoms continue following the remission of symptoms meeting Criterion A for schizophrenia. 

5. There may be associated alcohol and other substance-related disorders. 

Prevalence:

Lifetime: 0.3% 

One-third as common as schizophrenia. 

More common in females- due to depressive type

Development and Course:

Features appear in late teens and mid-30s

Onset can occur from adolescence to later life.

Typical age of onset- early adulthood

Etiology:

Genetic & Physiological- risk in first degree relatives with schizophrenia, bipolar disorder, schizoaffective disorder.