SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC

DISORDERS

Schizophrenia spectrum and other psychotic disorders include schizophrenia, other psychotic

disorders, and schizotypal (personality) disorder. They are defined by abnormalities in one or

more of the following five domains: delusions, hallucinations, disorganized thinking (speech),

grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms.

Key Features That Define the Psychotic Disorders

1. Delusions

Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence.

Their content may include a variety of themes (e.g., persecutory, referential, somatic, religious,

grandiose).

Persecutory delusions (i.e., belief that one is going to be harmed, harassed, and so forth by an

individual, organization, or other group) are most common.

Referential delusions (i.e., belief that certain gestures, comments, environmental cues, and so

forth are directed at oneself) are also common.

Grandiose delusions (i.e., when an individual believes that he or she has exceptional abilities,

wealth, or fame).

Erotomanic delusions (i.e., when an individual believes falsely that another person is in love

with him or her) are also seen.

Jealous type: This subtype applies when the central theme of the individual’s delusion

is that his or her spouse or lover is unfaithful.

Nihilistic delusions involve the conviction that a major catastrophe will occur.

Somatic delusions focus on preoccupations regarding health and organ function.

Delusions are deemed bizarre if they are clearly implausible and not understandable to

same-culture, peers and do not derive from ordinary life experiences.

An example of a bizarre delusion is the belief that an outside force has removed his or her

internal organs and replaced them with someone else's organs without leaving any wounds or

scars.

An example of a nonbizarre delusion is the belief that one is under surveillance by the police,

despite a lack of convincing evidence.

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

these include the belief that one's thoughts have been "removed" by some outside force {thought

withdrawal), that alien thoughts have been put into one's mind (thought insertion), or that one's

body or actions are being acted on or manipulated by some outside force (delusions of control).

The distinction between a delusion and a strongly held idea is sometimes difficult to make and

depends in part on the degree of conviction with which the belief is held despite clear or

reasonable contradictory evidence regarding its veracity.

2. 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.

- They may occur in any sensory modality, but auditory hallucinations are the most

common in schizophrenia and related disorders.

- Auditory hallucinations are usually experienced as voices, whether familiar or unfamiliar,

that are perceived as distinct from the individual's own thoughts.

- The hallucinations must occur in the context of a clear sensorium;

- Those that occur while falling asleep (hypnagogic) or waking up (hypnopompic) are

considered to be within the range of normal experience.

- Hallucinations may be a normal part of religious experience in certain cultural contexts.

3. Disorganized Thinking (Speech)

- Disorganized thinking (formal thought disorder) is typically inferred from the

individual's 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).

- Rarely, speech may be so severely disorganized that it is nearly incomprehensible and

resembles receptive aphasia in its linguistic disorganization {incoherence or "word

salad").

- Because mildly disorganized speech is common and nonspecific, the symptom must be

severe enough to substantially impair effective communication.

- The severity of the impairment may be difficult to evaluate if the person making the

diagnosis comes from a different linguistic background than that of the person being

examined.

- Less severe disorganized thinking or speech may occur during the prodromal and residual

periods of schizophrenia.

4. Grossly Disorganized or Abnormal motor Behavior (including Catatonia)

- Grossly disorganized or abnormal motor behavior may manifest itself in a variety of

ways. This include;

i) Childlike "silliness"

ii) Unpredictable agitation.

iii) Problems may be noted in any form of goal-directed behavior, leading to difficulties

in performing activities of daily living.

- Catatonic behavior is a marked decrease in reactivity to the environment. This ranges

from;

i) Resistance to instructions {negativism);

ii) Maintaining a rigid, inappropriate or bizarre posture;

iii) A complete lack of verbal and motor responses {mutism and stupor).

iv) Purposeless and excessive motor activity without obvious cause {catatonic

excitement).

v) Repeated stereotyped movements, staring, grimacing, mutism, and the echoing of

speech.

N/B

Although catatonia has historically been associated with schizophrenia, catatonic

symptoms are nonspecific and may occur in other mental disorders (e.g., bipolar or

depressive disorders with catatonia) and in medical conditions (catatonic disorder due to

another medical condition).

5. Negative Symptoms

Negative symptoms account for a substantial portion of the morbidity associated with

schizophrenia but are less prominent in other psychotic disorders.

 Two negative symptoms are particularly prominent in schizophrenia

i) Diminished emotional expression. Diminished emotional expression 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.

ii) Avolition. Avolition 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.

Other negative symptoms include; alogia, anhedonia, and asociality.

i) Alogia is manifested by diminished speech output.

ii) Anhedonia is the decreased ability to experience pleasure from positive

stimuli or a degradation in the recollection of pleasure previously

experienced.

iii) 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.

Schizotypal personality disorder

Remember: Schizophrenia spectrum and other psychotic disorders include schizophrenia, other

psychotic disorders, and schizotypal (personality) disorder.

The diagnosis schizotypal personality disorder captures a pervasive pattern of social and

interpersonal deficits. This include;

i) reduced capacity for close relationships

ii) cognitive or perceptual distortions;

iii) Eccentricities of behavior

- (Eccentricity is also called quirkiness) is unusual or odd behavior on the part of an individual.

- This behavior would typically be perceived as unusual or unnecessary, without being

demonstrably maladaptive. ...

- People who consistently display benignly eccentric behavior are labeled as "eccentrics.") ,

- This behavior usually begin by early adulthood but in some cases first becoming apparent

in childhood and adolescence.

iv) Abnormalities of beliefs, thinking, and perception are below the threshold for the

diagnosis of a psychotic disorder.

- Two conditions are defined by abnormalities limited to one domain of psychosis:

delusions or catatonia. Delusional disorder is characterized by at least 1 month of

delusions but no other psychotic symptoms.

- Brief psychotic disorder lasts more than 1 day and remits by 1 month.

- Schizophreniform disorder is characterized by a symptomatic presentation equivalent to

that of schizophrenia except for its duration (less than 6 months) and the absence of a

requirement for a decline in functioning.

- Schizophrenia lasts for at least 6 months and includes at least 1 month of active-phase

symptoms.

- In schizoaffective disorder, a mood episode and the active-phase symptoms of

schizophrenia occur together and were preceded or are followed by at least 2 weeks of

delusions or hallucinations without prominent mood symptoms.

- Psychotic disorders may be induced by another condition. In substance/medication

induced psychotic disorder, the psychotic symptoms are judged to be a physiological

 consequence of a drug of abuse, a medication, or toxin exposure and cease after removal

of the agent. In psychotic disorder due to another medical condition, the psychotic

symptoms are judged to be a direct physiological consequence of another medical

condition.

- Catatonia can occur in several disorders, including neurodevelopmental, psychotic,

bipolar, depressive, and other mental disorders.

Differential Diagnosis

1. Major depressive or bipolar disorder with psychotic or catatonic features. The distinction

between schizophrenia and major depressive or bipolar disorder with psychotic features

or with catatonia depends on the temporal relationship between the mood disturbance and

the psychosis, and on the severity of the depressive or manic symptoms. If delusions or

hallucinations occur exclusively during a major depressive or manic episode, the

diagnosis is depressive or bipolar disorder with psychotic features.

2. Schizoaffective disorder. A diagnosis of schizoaffective disorder requires that a major

depressive or manic episode occur concurrently with the active-phase symptoms and that

the mood symptoms be present for a majority of the total duration of the active periods.

3. Schizophreniform disorder and brief psychotic disorder. These disorders are of shorter

duration than schizophrenia which requires 6 months of symptoms. In schizophreniform

disorder, the disturbance is present less than 6 months, and in brief psychotic disorder,

symptoms are present at least 1 day but less than 1 month.

4. Delusional disorder. Delusional disorder can be distinguished from schizophrenia by the

absence of the other symptoms characteristic of schizophrenia (e.g., delusions, prominent

 auditory or visual hallucinations, disorganized speech, grossly disorganized or catatonic

behavior, negative symptoms).

5. Schizotypal personality disorder. Schizotypal personality disorder may be distinguished

from schizophrenia by sub threshold symptoms that are associated with persistent

personality features.

6. Obsessive-compulsive disorder and body dysmorphic disorder. Individuals with

obsessive-compulsive disorder and body dysmorphic disorder may present with poor or

absent insight, and the preoccupations may reach delusional proportions. But these

disorders are distinguished from schizophrenia by their prominent obsessions,

compulsions, preoccupations with appearance or body odor, hoarding, or body-focused

repetitive behaviors.

7. Posttraumatic stress disorder. Posttraumatic stress disorder may include flashbacks that

have a hallucinatory quality, and hypervigilance may reach paranoid proportions. But a

traumatic event and characteristic symptom features relating to reliving or reacting to the

event are required to make the diagnosis.

8. Autism spectrum disorder or communication disorders. These disorders may also have

symptoms resembling a psychotic episode but are distinguished by their respective

deficits in social interaction with repetitive and restricted behaviors and other cognitive

and communication deficits. An individual with autism spectrum disorder or

communication disorder must have symptoms that meet full criteria for schizophrenia,

with prominent hallucinations or delusions for at least 1 month, in order to be diagnosed

with schizophrenia as a comorbid condition.

 9. Delirium or major or minor neurocognitive disorder may present with psychotic

symptoms, but these would have a temporal relationship to the onset of cognitive changes

consistent with those disorders. Individuals with substance/medication-induced psychotic

disorder.

10. Substance/medication-induced psychotic disorder can usually be distinguished by the

chronological relationship of substance use to the onset and remission of the psychosis in

the absence of substance use.

Risk and Prognostic Factors

Factors associated with schizophrenia

No known cause. A number of factors that can play part have been suggested;

1. Heredity

- If one parent has schizophrenia then the child has 20% chance of developing

schizophrenia

2. Physical factors

- According to kretschmer’s theory about ½ of the schizophrenic are of asthenic or

leptosomatic body build (tall, narrow chested, long extremities and poor muscular

development)

3. Environmental and social factors

- Factors such as maternal deprivation, loss of one parent or both, family disharmony

etc.

4. Premorbid personality
- Much attention has been paid to that period before schizophrenia developed. It has

been said that 50% of the individuals with schizophrenia are by nature shy, withdrawn,

often sensitive and hard to influence

- They often live in world of fancies and show very little interest in whatever goes

around them. It is due to these “shut in” traits that these individuals fail to meet everyday

responsibilities and stresses and thus turn back into themselves and sink low on the social

scale.

Precipitating factors

• Head injury

• Infections

• Surgical operations

• Abuse of alcohol and drugs e.g. amphetamine and lysergic acid

Predisposing factors

- Genetic

- Environmental

- Abnormalities in pregnancy and delivery

- Maternal influenza (2nd trimester)

- Fetal malnutrition

- Winter birth

Precipitating factors

- Chronic cannabis consumption

Maintaining factors

- Strongly expressed feeling especially in the form of critical thinking.

Major Forms of Schizophrenia

1. Simple schizophrenia

- It consists of a progressive mental deterioration occurring about the pubertal age or early

life and sometimes in individuals who already have some degree of intellectual defect.

- The patient lack volition and may suffer from peculiar mannerism and negativism (active

negativism-doing opposite of what they are told, passive negativism-a person fails to co-operate

as in depression and schizophrenia).

- It may take long time for these behaviors to be recognized as abnormal. These patients

are often shiftless individual who move from house to house, job to job, town to town. They

score low in vagrancy, prostitution, crime etc.

2. Hebephrenic schizophrenia (hebephrenia)

- It develops gradually before the age of 30.Common features include

- Impaired rapport

- Disturbance of behavior

- Disturbance of affect

- Thoughtless, cheerfulness and silly behavior

- Common in men
- At onset patient may complain of headache and malaise

- May then often become depressed, dull, irritable, apathetic (state of having no wish to act

or enthusiasm) and tend to avoid company of others

- Thought disorder is the main symptoms in this illness and suicidal attempts are common.

- The patient may progressively become childish and silly often giggling and laughing

despite the apparent state of depression.

3. Catatonic schizophrenia (catatonia)

- Common In females at age of 25 yrs

- Disturbance of motor behavior are most common features

- The disorder appear in two main forms

Depressive phase (catatonic stupor)

Characterized by insomnia, depression, limitation of activity and gradual withdrawal

from contact with the environment.

Hallucination, negativism and mutism are common.

Features of waxy flexibility (flexibilitas erea) in which the patient is capable for very

long periods may be observed. Patients limbs can be moulded into a position and remain fixed

for a long period of time

Excitement phase

It can be mistaken with acute mania

• But when the manic patient shows a pressure of activity, the activity is quite purposive

whereas the activity of catatonia is silly, stereotyped, purposeless and quite violent and

impulsive.
• In mania, hallucination are absent whereas they are always present in Catatonia.

• Catatonics are negativistic compared with manics.

• The mood in manics is warm and expansive(friendly talkative, extravagant), whereas the

catatonic lacks rapport

4. Paranoid schizophrenia

Characterized by delusions. The delusions are illogical and of grandeurs or persecution or both

and may be accompanied by auditory hallucinations.

The rest of the personality tends to be preserved.

Management of Schizophrenia

Aims

1. Suppression of symptoms

2. Prevention of deterioration

3. Rehabilitation of the patient

The nurse should assist the psychiatrist with mental status assessment of the patient so as

to differentiate his illness from other psychotic conditions (neurotic and psychotic). This helps to

provide differential diagnosis

Nurse the patient in a calm non-stimulating atmosphere since noise and activities tend to

worsen a disturbed mind.

Observe the general behavior of the patient closely. This will help to prevent self-

destruction and harming other people.

 Administer tranquillizer of phenothiazine group as prescribed by psychiatrist e.g.

chlorpromazine (largatil) 100mg-900mg daily in divided doses depending on the severity of the

condition.

Common ones;

First Generation,” Typical or conventional’ antipsychotics

1. Haloperidol
PO

 Moderate disease, 0.5-2 mg q8-12hr initially

 Severe disease, 3-5 mg q8-12hr initially; not to exceed 30 mg/day

IM lactate (prompt-acting)

 2-5 mg q4-8hr PRN; may require q1hr in acute agitation; not to exceed 20 mg/day

IM decanoate (depot)

 Initial: IM dose 10-20 times daily PO dose administered monthly; not to exceed 100 mg;
if conversion requires initial dose >100 mg, administer in 2 injections (eg, 100 mg
initially, then remainder in 3-7 days)
 Maintenance: Monthly dose 10-15 times daily PO dose

2. Chlorpromazine (Thorazine, Largactil) Dosage Forms & Strengths

Tablet

 10mg
 25mg
 50mg
 100mg
 200mg

injectable solution

 25mg/mL

PO: 30-75 mg/day divided q6-12hr initially; maintenance: usually 200 mg/day (up to 800
mg/day in some patients; some patients may require 1-2 g/day)
IV/IM: 25 mg initially, followed PRN with 25-50 mg after 1-4 hours, then increased to
maximum of 400 mg q4-6hr until patient is controlled; usual dosage 300-800 mg/day

3. Fluphenazine (Prolixin, Modecate)

Dosage Forms & Strengths

tablet

 1mg
 2.5mg
 5mg
 10mg

elixir

 2.5mg/5mL

oral concentrate

 5mg/mL

injectable solution

 2.5mg/mL (fluphenazine hydrochloride)

 25mg/mL (fluphenazine decanoate)

Fluphenazine hydrochloride

 2.5-10 mg/day PO divided q6-8hr initially; maintenance: 1-5 mg PO/IM divided q6-8hr;
not to exceed 40 mg/day

Fluphenazine decanoate

 16.25-25 mg (25 mg/mL) IM/SC q2weeks; after achieving steady state, effects of a single
injection may last 4-6 weeks; use caution titrating dosages; if doses >50 mg needed; use
increments of 12.5 mg; not to exceed 100 mg

Dosing considerations

 Conversion from oral hydrochloride salt to decanoate dosage form: 12.5 mg of decanoate
every 3 weeks is approximately equivalent to 10 mg/day of oral hydrochloride and 12.5
mg/day IM/SC
 4. Thioridazine (Mellaril)

5. Trifluoperazine (Stelazine)

Second Generation,” or atypical’ antipsychotics

1. Aripiprazole lauroxil (Aristada)

2. Clozapine (Clozaril)

3. Olanzapine (Zyprexa)

4. Quetiapine (Seroquel)

5. Risperidone(Risperdal)

Nurse should prepare the patient for ECT. The patient should be prepared as any

other patient for surgical operation under general anaesthesia.

Nurse to observe for both immediate and long term side effect.

- The immediate one includes headache, dizziness and confusion.

- The long term ones include loss of memory.

If ECT is given with largactil then a drop in blood pressure may be realized. The normal dose of

ECT is 3 doses given alternate days. But in some cases depending on the patient condition 4 or 5

doses may be given on alternate days.

Encourage the patient to actively participate in his environmental hygiene

As the condition of the patient improves, encourage him to participate in therapeutic

groups. This will help the patient to abandon the withdrawal symptoms and start socializing with

others. This help the patient to learn how to form personal relationships
 Encourage the patient to participate in occupational and recreational therapy to prevent

boredom and keep his mind off thought. He should also spend at least part of each day working

at some task that is rewarding both psychologically and financially. This will help him return to

normal employment as soon as possible

Encourage emotional expression by developing a friendship and relationship with the

patient

Give the patient a balanced high caloric diet. This will enable the patient get enough

strength to go through other treatments. A good diet is also important for metabolism of the

antipsychotic drugs. It helps to minimize side effects.

Provide health education to the patient and his family members about the cause, signs and

symptoms of schizophrenia. Include information about the care of the patient at home. The

patient should take drugs as ordered and visit the clinic as directed. The family members should

watch for the side effects of those drugs, create a healthy atmosphere at home and aid the patient

in reducing problems.

Organize a follow-up by social workers

Prognosis

A schizophrenic illness should never be taken lightly, though the outcome is not always

unfavorable, the younger the patient the poorer the prognosis. If the onset is acute, then this is

thought to be the most reliable pointer of good prognosis.

A slow insidious onset with marked ego disorder and flat mood are generally pointers of poor

prognosis