Schizophrenia spectrum and

other psychotic disorders

2022
Schizophrenia spectrum and other psychotic
disorders
• Abnormalities in one or more of the following five domains:
1. Delusions,
2. Hallucinations,
3. Disorganized thinking (speech),
4. Grossly disorganized or abnormal motor behavior (including
catatonia),
5. Negative symptoms.
Delusions
• Delusions are fixed beliefs that are not amenable to change in light of conflicting
evidence.

• Persecutory delusions (i.e., belief that one is going to be harmed, harassed),

• Referential delusions (i.e., belief that certain gestures, comments,
environmental cues, and so forth are directed at oneself)
• 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)
• Nihilistic delusions involve the conviction that a major catastrophe will occur,
• Somatic delusions focus on preoccupations regarding health and organ function.
Delusions
• Bizarre delusions - thought withdrawal, thought insertion, delusions
of control outside force has removed his or her internal organs

• Nonbizarre delusion is the belief that one is under surveillance by the

police, despite a lack of convincing evidence.
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

• Auditory hallucinations are the most common in schizophrenia and

related disorders.
 Disorganized Thinking
formal thought disorder

• Derailment or loose associations - The individual may switch from one

topic to another

• Tangentiality - Answers to questions may be obliquely related or

completely unrelated

• Incoherence or word salad- severely disorganized speech, nearly

incomprehensible and resembles receptive aphasia in its linguistic
disorganization

• Symptom must be severe enough to substantially impair effective

communication.
 Grossly Disorganized or Abnormal Motor Behavior

• Childlike "silliness"
• Unpredictable agitation.

Catatonic behavior is a marked decrease in reactivity to the

environment.
• Negativism;
• Stupor and mutism
• Catatonic excitement
• Stereotyped movements, staring, grimacing
• Echoing of speech.
https://www.youtube.com/watch?v=gYwGmWWxY48
Catatonia
A. The clinical picture is dominated by three (or more) of the following symptoms:
• 1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
• 2. Catalepsy (i.e., passive induction of a posture held against gravity).
• 3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
• 4. Mutism (i.e., no, or very little, verbal response
• 5. Negativism (i.e., opposition or no response to instructions or external stimuli).
• 6. Posturing (i.e., spontaneous and active maintenance of a posture against
gravity).
• 7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
• 8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed
movements).
• 9. Agitation, not influenced by external stimuli.
• 10. Grimacing.
• 11. Echolalia (i.e., mimicking another’s speech).
• 12. Echopraxia (i.e., mimicking another’s movements).
Negative Symptoms
• 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

• 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

• Alogia is manifested by diminished speech output.

• Anhedonia is the decreased ability to experience pleasure from

positive stimuli or a degradation in the recollection of pleasure
previously experienced.

• Poverty of content of speech. Although the patient’s replies are

long enough so that speech is adequate in amount, it conveys little
information.
Schizophrenia Spectrum and Other Psychotic
Disorder
• Schizotypal (Personality) Disorder
• Delusional Disorder
• Brief Psychotic Disorder
• Schizophreniform Disorder
• Schizophrenia
• Schizoaffective Disorder
• Substance/Medication-Induced Psychotic Disorder
• Psychotic Disorder Due to Another Medical Condition
https://www.youtube.com/watch?v=ZB28gfSmz1Y
Delusional Disorder
• 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

• Hallucinations, if present, are not prominent and 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 bizarre or odd.
Specify whether:
• Erotomaniac type

• Grandiose type

• Jealous type

• Persecutory type

• Somatic type

• With bizarre content

Prevalence

• The lifetime prevalence of delusional disorder has been estimated at

around 0.2%

• Most frequent subtype is persecutory delusional disorder

• Jealous type, is more common in males than in females,

• No major gender differences in the overall frequency of delusional

disorder.
Differential Diagnosis
• Schizophrenia and schizophreniform disorder

• Obsessive-compulsive and related disorders (obsessive-compulsive

disorder, with absent insight/delusional)

• beliefs specifier

• Depressive and bipolar disorders and schizoaffective disorder

 Brief Psychotic Disorder
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

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 other psychotic disorder and is not
attributable to the physiological effects of a substance or another medical condition.
Specify if:

• With marked stressor(s)

• Without merited stressor(s)

• With postpartum onset: If onset is during pregnancy or within 4

weeks postpartum

• With catatonia
Associated Features Supporting Diagnosis
• Individuals with brief psychotic disorder typically experience emotional
turmoil or overwhelming confusion

• They may have rapid shifts from one intense affect to another

• The level of impairment may be severe, and supervision may be required

• Increased risk of suicidal behavior, particularly during the acute episode

Prevalence
• In the United States, brief psychotic disorder may account for 9% of
cases of first-onset psychosis.

• Psychotic disturbances that meet Criteria A and C, but not Criterion B,

for brief psychotic disorder (i.e., duration of active symptoms is 1-6
months as opposed to remission within 1 month) are more common
in developing countries than in developed countries

• Brief psychotic disorder is twofold more common in females than in

males.
 Schizophreniform Disorder
• 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).
Schizophreniform Disorder
• 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

• 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.
Development and Course
• The development of schizophreniform disorder is similar to that of
schizophrenia

• About one-third of individuals with an initial diagnosis of schizophreniform

disorder (provisional) recover within the 6-month period and
schizophreniform disorder is their final diagnosis

• The majority of the remaining two-thirds of individuals will eventually receive

a diagnosis of schizophrenia or schizoaffective disorder.

• Schizophreniform disorder differs in duration from brief psychotic disorder,

which has a duration of less than 1 month.
Schizoaffective disorder
• Classified as having schizoaffective disorder, atypical schizophrenia, good-
prognosis schizophrenia, remitting schizophrenia, and cycloid psychosis

• 1970, two sets of data shifted the view of schizoaffective disorder from a
schizophrenic illness to a mood disorder:
1. Lithium
2. 1968 by John Cooper and his colleagues showed that the number of
patients classified as schizophrenic in the United States and in the United
Kingdom resulted from an overemphasis in the United States on the
presence of psychotic symptoms as a diagnostic criterion for
schizophrenia.
Schizoaffective disorder
• A. An uninterrupted period of illness during which there is a major
mood episode (major depressive or manic) concurrent with Criterion
A of schizophrenia.
• 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 if:
The following course specifiers are only to be used after a 1-year
duration of the disorder
• First episode, currently in acute episode or currently in partial
remission or currently in full remission
• Multiple episodes (after a minimum of two episodes) currently in
acute episode currently in partial remission currently in full remission

• Bipolar type
• Depressive type
• With catatonia
Epidemiology
• The lifetime prevalence range of 0.5 to 0.8%

• Approximately equal numbers of men and women have the bipolar subtype
and are more than twofold female to male predominance among individuals
with the depressed subtype

• The depressive type of schizoaffective disorder may be more common in older

persons than in younger persons, and the bipolar type may be more common
in young adults than in older adults.

• The age of onset for women is later than that for men, as in schizophrenia.

• Men with schizoaffective disorder are likely to exhibit antisocial behavior and
to have a markedly flat or inappropriate affect.
Schizophrenia
https://www.bbrfoundation.org/healthy-minds-tv
 Eugen Bleuler

Emil Kraepelin
Kurt Schneider
Michelle G. Craske et al. 2017
 Definition

• Schizophrenia is a chronic, debilitating mental disorder

characterized by periods of loss of touch with reality (psychosis);

• Persistent disturbances of thought, behavior, appearance, and

speech; abnormal affect; and social withdrawal.

 Epidemiology

• Peak age of onset of schizophrenia is 15–25 years for men and 25–
35 years for women.

• Schizophrenia occurs equally in men and women, all cultures, and

all ethnic groups studied.
The Complexity of Schizophrenia

• No single defining feature

• Multiple characteristic symptoms
• Symptoms from multiple domains
• Emotion
• Personality
• Cognition
• Motor Activity
• Probably a multisystem disorder
Schizophrenia
Diagnostic Criteria 295.90 (F20.9)
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).
Schizophrenia
Diagnostic Criteria 295.90 (F20.9)
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.
 Simplifying the Complexity of
Schizophrenia

• Division of symptoms into two broad groups

• Positive: distortions or exaggerations of normal

functions

• Negative: diminution of normal functions

 Symptoms of schizophrenia

Positive Negative
• Delusions, • Lack o motivation,
• Hallucinations, • Social withdrawal,
• Agitation, • Flattened affect,
• Disorganization • Poor grooming,
• Catatonia • Poor (i.e., impoverished)
speech content.
 Positive Symptoms
Symptom Function Distorted
Hallucinations Perception
Delusions Inferential thinking
Disorganized Speech Thought/Language
Bizarre Behavior Behavioral monitoring
 Negative Symptoms
Symptom Function Diminished

Alogia Fluency of
Affective blunting speech/thought
Avolition Emotional expression
Anhedonia Volition and drive
Hedonic capacity
 The Importance of Negative
Symptoms
• Impair ability to function in daily life
• Holding a job
• Attending school
• Forming friendships
• Having intimate family relationships
Subdivision of Symptoms into Three
Dimensions
Psychotic
Delusions
Hallucinations
Disorganized
Disorganized speech
Disorganized behavior
Inappropriate affect
Negative
Poverty of speech
Avolition
Affective Blunting
Anhedonia
 DSM-5 Criteria for Schizophrenia:
The Basics

• Characteristic symptoms for one month

• Social/Occupational Dysfunction
• Overall Duration > 6 months
• Not attributable to mood disorder
• Not attributable to substance use or general medical
condition
 Form of thought

• Circumstantiality
Inclusion of too much detail When asked about her health, the patient
explains everything that she did since getting up that day before getting
to the subject of her health

• Loose associations
Shift of ideas from one subject to another in an unrelated way. The
patient begins to answer a question about her health and then
shifts to a statement about baseball
 Form of thought

• Neologisms
Inventing new words The patient refers to her doctor as a “medocrat”

• Perseveration
Repeating words or phrases The patient says, “I’m evil, I’m evil, I’m evil”

• Tangentiality
Getting further away from the point as speaking continues. The patient
begins to answer a question about her health and ends up talking about
her sister’s abortion; she never gets back to the subject of her health
 Thought processes

• Impaired abstraction ability

Problems discerning the essential qualities of objects or relationships.
When asked what brought her to the emergency room, the patient
says, “An ambulance”

• Magical thinking
Belief that thoughts affect the course of events. Knocking on wood to
prevent something bad from happening
DSM-5 Dimensions of Psychotic Symptom Severity in Schizophrenia (rated
over the past 7 days as 0 = not present; 1 = equivocal; 2 = present but mild;
3 = present and moderate; or 4 = present and severe)
Hallucinations Severe pressure to respond to auditory
hallucinations (voices) or is very upset by the
voices
Delusions Severe pressure to act upon the delusions
(false beliefs) or is very upset by the false
beliefs
Disorganized speech Speech is almost impossible to follow
Abnormal psychomotor Severe abnormal or bizarre motor behavior or
behavior almost constant catatonia (stupor with lack of
coherent speech)
Negative symptoms Severe decrease in facial expressivity,
gestures, or self-initiated behavior
 Course
• Prodromal signs and symptoms occur prior to the first psychotic
episode and include avoidance of social activities; physical
complaints; and new interest in religion, the occult, or philosophy.

• Active phase, the patient loses touch with reality. Disorders o

perception, thought content, thought processes, and form o thought
occur during an acute psychotic episode.

• Residual phase (time period between psychotic episodes), the patient

is in touch with reality but does not behave normally. This phase is
characterized by negative symptoms.
 Prognosis

• Schizophrenia usually involves repeated psychotic episodes and a

chronic, downhill course over years.

• Suicide is common in patients with schizophrenia. More than 50%

attempt suicide and 10% of those die in the attempt.

 Poor Outcome: Predictors
• Prominent negative symptoms
• Early age of onset
• Insidious onset
• Poor premorbid adjustment
• Low educational achievement
• Low parental social class
• Male gender
“Good Prognosis Schizophrenia”
• Prominent affective symptoms and family history of
affective disorder
• Acute onset
• Few negative symptoms and few relapses
• Good premorbid function
• Good social support
• Presence of insight
• Female gender
• The patient is older at onset of illness
The Genetics of Schizophrenia
 Etiology

• Genetic factors
• Certain chromosomal markers have been associated with schizophrenia

Other factors
a. The season of birth is related to the occurrence o schizophrenia.
b. No social or environmental factor causes schizophrenia. However, because
patients with schizophrenia tend to drift down the socioeconomic scale as a
result of their social deficits (the “downward drift” hypothesis), they are
often found in lower socioeconomic groups (e.g., homeless people).
Schizophrenia
• Lifetime prevalence of 0.6 to 1 .9 percent

• Equally prevalent in men and women

• The peak ages of onset are 1 0 to 25 years for men and 25 to 35 years
for women

• Approximately 3 to 1 0 percent of women with schizophrenia present

with disease onset after age 40 years
Mortality rate
• Persons with schizophrenia have a higher mortality rate from
accidents and natural causes than the general population

• Several studies have shown that up to 80 percent of all schizophrenia

patients have significant concurrent medical illnesses

• 50 percent of these conditions may be undiagnosed

Infection and Birth Season
• More likely to have been born in the winter and early spring

• Season specific risk factors, such as a virus or a seasonal change in

diet, may be operative.

• Gestational and birth complications, exposure to influenza epidemics,

maternal starvation during pregnancy, rhesus factor incompatibility
Substance abuse
• The lifetime prevalence of any drug abuse (other than tobacco) is
often greater than 50%

• Those reporting high levels of cannabis use (more than 50 occasions)

were at six fold increased risk of schizophrenia compared with
nonusers

• ifetime prevalence of alcohol within schizophrenia was 40 percent

Psychoanalytic Theories
• Sigmund Freud - Ego disintegration in schizophrenia represents a return to the time when
the ego was not yet developed or had just begun to be established

• Margaret Mahler - distortions in the reciprocal relationship between the infant and the
mother. The child is unable to separate from, and progress beyond, the closeness and
complete dependence that characterize the mother-child relationship in the oral phase of
development. As a result, the person's identity never becomes secure

• "schizophrenogenic mother" - This term designates a mother who is not capable of

drawing a clear boundary between herself and her child. The double-bind concept

• Learning Theories - children who later have schizophrenia learn irrational reactions and
ways of thinking by imitating parents who have their own significant emotional problems
Family
• Schisms and Skewed Families - one parent is overly close to a child of
the opposite gender. In the other family type, a skewed relationship
between a child and one parent involves a power struggle between
the parents and the resulting dominance of one parent.
• Pseudomutual and Pseudohostile - Families. As described by Lyman
Wynne, some families suppress emotional expression by consistently
using pseudomutual or pseudohostile verbal communication. In such
families, a unique verbal communication develops, and when a child
leaves home and must relate to other persons, problems may arise.
• Expressed Emotion - Parents or other caregivers may behave with
overt criticism, hostility, and overinvolvement toward a person with
schizophrenia.
 Brain Abnormalities
• Abnormalities of the frontal lobes, as evidenced by decreased use of
glucose in the frontal lobes on positron emission tomography (PET)
scans

• Lateral and third ventricle enlargement, abnormal cerebral symmetry,

and changes in brain density also may be present.

• Decreased volume of limbic structures (e.g., amygdala, hippocampus)

is also seen.
1% to 3% in the temporal lobe, the frontal lobe, and the parietal lobe. Thompson et al, 2001
Loss of brain volume associated with schizophrenia is clearly shown by magnetic resonance imaging (MRI) scans
comparing the size of ventricles (butterfly shaped, fluid-filled spaces in the midbrain) of identical twins, one of
whom has schizophrenia (right). The ventricles of the twin with schizophrenia are larger. This suggests structural
brain changes associated with the illness. Note that such MRI scans cannot be used to diagnose schizophrenia in the
general population, due to normal genetic variation in ventricle size -- many unaffected people have large ventricles.
Source: Daniel Weinberger, M.D. NIMH Clinical Brain Disorders Branch
Black et al
 Neurotransmitter abnormalities
• Schizophrenia Dopamine (↑), serotonin (↑), glutamate (↑ or ↓)
 Management

• Pharmacologic management traditional antipsychotics (dopamine- 2

[D2]-receptor antagonists) and atypical antipsychotic agents. Long-
acting injectable “depot” forms.

• Psychological management, including individual, family, and group

psychotherapy
Schizophrenia and Other Psychotic Disorders
• Brief psychotic disorder <1 month

• Schizophreniform disorder 1–6 months

• Schizoaffective disorder

• Schizophrenia at least 6 months

• Delusional disorder

• Delusional disorder in partner of individual with delusional disorder

Substance/Medication-Induced Psychotic Disorder
A. Presence of one or both of the following symptoms:
1. Delusions.
2. Hallucinations.
B. There is evidence from the history, physical examination, or
laboratory findings of both
(1)and (2):
1. The symptoms in Criterion A developed during or soon after
substance intoxication or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the
symptoms in Criterion A.
Substance/Medication-Induced psychotic
disorder
• C. The disturbance is not better explained by a psychotic disorder that
is not substance/ medication-induced. Such evidence of an
independent psychotic disorder could include the following: The
symptoms preceded the onset of the substance/medication use; the
symptoms persist for a substantial period of time (e.g., about 1
month) after the cessation of acute withdrawal or severe intoxication

• D. The disturbance does not occur exclusively during the course of a

delirium.
Specify if
• With onset during intoxication: If the criteria are met for intoxication
with the substance and the symptoms develop during intoxication.

• With onset during withdrawal: If the criteria are met for withdrawal
from the substance and the symptoms develop during, or shortly
after, withdrawal.