Chapter 7 (Psychotic Disorders)

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Chapter 7: Psychotic Disorders

• This chapter discusses psychotic disorders.

Learning Objectives

• Outline the defining symptoms of psychosis.
• Describe the symptoms of DSM-5 psychotic disorders and problems associated with psychosis.
• Explain the evolution of schizophrenia diagnostic criteria and controversies surrounding the diagnosis.
• Outline the prevalence, age of onset, and stages of psychosis.
• Describe the various factors involved in the aetiology of psychosis.
• Describe main treatment priorities and evidence-based treatment options in relation to psychosis phases.

Historical Conceptualisations of Psychotic Disorders

• Kraeplin identified 'dementia praecox', meaning 'senility of the young'.
• Bleuler coined the term 'schizophrenia' meaning 'split mind'.
• Schneider argued for 'first rank symptoms' that were specific to schizophrenia.

Schizophrenia(s)

• Eugen Bleuler noted that schizophrenia involved various diseases.

DSM-5 Types of Psychotic Disorders

• Schizophrenia: At least one month of two or more of the following: delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behaviour, and/or negative symptoms. The disturbance must last at least six months.
• Schizotypal disorder: Pervasive social and interpersonal deficits and cognitive/perceptual distortions and eccentricities of behaviour beginning before early adulthood.
• Schizophreniform disorder: Equivalent to schizophrenia but with a shorter disturbance (one to six months).
• Schizoaffective disorder: Co-occurrence of schizophrenia and a major mood episode, with at least a two-week period of delusions or hallucinations without mood disturbance. Mood symptoms are present for most of the illness duration.
• Delusional disorder: At least one month of delusions.
• Brief psychotic disorder: A psychotic disturbance lasting between one day and a month and returning to premorbid functioning.
• Psychotic disorder due to another medical condition: Prominent hallucinations or delusions resulting from another medical condition.
• Substance/medication-induced psychotic disorder: Hallucinations or delusions arising from substance intoxication or withdrawal.
• Other specified schizophrenia spectrum and other psychotic disorder: Symptoms of psychosis causing distress or impairment but not fully meeting criteria for another psychotic disorder.
• Unspecified schizophrenia spectrum and other psychotic disorder: Symptoms of psychosis causing distress or impairment but not meeting criteria of any psychotic disorder (no specific reasons are provided).

Key Features of the Psychotic Disorders

• Delusions
• Hallucinations
• Disorganized Thinking
• Disorganized or Abnormal Motor Behaviour
• Negative Symptoms

Principal Psychotic Experiences: Delusions

• Firmly held beliefs opposed to reality but maintained despite contrary evidence.

Principal Psychotic Experiences: Hallucinations

• Perceptual experiences involving perceiving something that is not there (positive) or not perceiving something that is there (negative).

Kinds of Delusions

• Bizarre: Implausible according to the person's culture.
• Delusional jealousy: Delusion that relational partner is unfaithful.
• Erotomanic: Delusion that another person is in love.
• Grandiose: Delusion of inflated worth, power, knowledge, identity, or special relationship to a deity.

Kinds of Delusions

• of being controlled: Experiences of actions, thoughts, or impulses being controlled by an external force.
• of Reference: Delusion that events or objects have special significance to the individual.
• Persecutory: Delusion that one (or someone close) is being attacked, harassed, cheated, persecuted, or conspired against.
• Somatic: Delusions related to body appearance or functioning.
• Thought broadcasting: Delusion that one's thoughts are being heard by others.
• Thought insertion: Delusion that thoughts are not one's own, but rather are inserted into one's mind.

Delusional Content in Various Disorders

• Schizophrenia (examples of various contents)
• Depressive disorders (examples of various contents)
• Bipolar disorders (mania)(examples of various contents)
• Delusional disorder (examples of various contents)

Kinds of Hallucinations

• Auditory: Perception of sounds (most commonly voices).
• Gustatory: Perception of taste (usually unpleasant).
• Olfactory: Perception of odours.
• Somatic: Perception of physical sensations in the body.
• Tactile: Perception of touch or something crawling on skin.
• Visual: Perception of images, flashes of light, or people.

Disorganised Thinking in Psychotic Disorders

• Disorganisation
• Loosening of associations
• Confusion
• Disturbances in logical sequencing

DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders (List)

• Schizophrenia
• Schizophreniform disorder
• Brief psychotic disorder
• Schizoaffective disorder
• Delusional disorder
• Schizotypal (personality) disorder
• Substance-induced psychotic disorder
• Psychotic disorder due to a medical condition

DSM-5-TR Diagnostic Criteria for Schizophrenia

• Two or more of the following, present for a significant portion of one-month period.
• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms
• Marked below premorbid functioning in at least one aspect of life.
• Must have continuous signs lasting at least 6 months

DSM-5-TR: Schizophreniform Disorder

• Similar to schizophrenia, but with a shorter episode (at least 1 month but not exceeding 6 months).

DSM-5-TR: Brief Psychotic Disorder

• Psychotic symptoms that last at least one day but less than one month.
• Return to premorbid level of functioning.

DSM-5-TR Diagnostic Criteria for Schizoaffective Disorder

• Major mood episode (depression or mania) concurrently with schizophrenia symptoms.
• Symptoms of delusions or hallucinations should be present for a period without mood episode

DSM-5-TR Diagnostic Criteria for Delusional Disorder

• One or more delusions lasting at least one month.
• Criterion A for schizophrenia has never been met.
• Functioning is not markedly impaired, and the behavior is not bizarre or odd.

Subtypes of Delusional Disorder

• Erotomanic
• Grandiose
• Jealous
• Persecutory
• Somatic

Epidemiology of Schizophrenia

• Lifetime prevalence is approximately 1-2%
• Men are slightly more affected than women.
• Increased prevalence rate in developed nations and urban settings.
• Onset typically during late adolescence and early adulthood.

Epidemiology of Schizophrenia: Course

• Premorbid phase: Period before symptoms.
• Prodromal phase: Period before onset of full symptoms.
• Acute phase: Active positive and negative symptoms.
• Early recovery phase: Reduction in depressive or anxious symptoms.
• Later recovery: Challenges with reintegration into social, recreational, and vocational pursuits.

Epidemiology of Schizophrenia: Associated Features

• Depression is often prevalent in patients with psychosis.
• High rates of suicide attempts are common in psychotic disorders.
• Anxiety and trauma-related problems are common
• Substance abuse is a common aspect of psychosis

Aetiology of Schizophrenia: Genetic Research

• Genetic factors don't fully explain the disorder.
• Diathesis-stress model: Genetic predisposition + stress triggers onset.
• Possible genetic heterogeneity among individuals.

Aetiology of Schizophrenia: Neurotransmitters

• Dopamine theory (excess dopamine levels; drugs that reduce dopamine activity may reduce symptoms but takes a while.)
• Revised dopamine theory (excess number of dopamine receptors or overly sensitive receptors; dopamine abnormalities related to positive symptoms)

Aetiology of Schizophrenia: Brain Structure and Function

• Enlarged ventricles.
• Reduced activity in prefrontal cortex.
• Developmental factors (prefrontal cortex matures in adolescence).
• Stress activates HPA system (increasing cortisol and dopamine activity).

Treatment of Schizophrenia: Medications

• First-generation antipsychotics (Phenothiazines, butyrophenones).
• Second-generation antipsychotics (Clozapine, olanzapine,risperidone.)
• Newer medications may improve cognitive function.

Treatment of Schizophrenia: Psychological Approaches

• Patient Outcomes Research Team (PORT) recommendations.
• Social skills training, and cognitive behavioral therapy.
• Family therapy to reduce expressed emotion.
• Treatments with a focus on reducing relapse.

Treatment of Schizophrenia: Prodromal Phase

• Emphasis on early detection and intensive intervention to prevent progression.
• Evidence for use of antipsychotics combined with CBT.

Treatment of Schizophrenia: Acute Phase

• Needs 24-hour access to treatment (hospitalisation).
• Pharmacological approaches (antipsychotics).
• Psychosocial approaches (addressing co-morbidities).