Schizophrenia Spectrum and Other Psychotic Disorders PDF

Schizophrenia Spectrum and Other Psychotic Disorders David Montero MD, Psychotherapist  Objectives 1. Describe the psychopathology of psychosis. (Positive, Negative, Cognitive, Speech, Behavior) 2. Identify the disorders in the psychotic disorder's...

Schizophrenia Spectrum and Other Psychotic Disorders David Montero MD, Psychotherapist  Objectives 1. Describe the psychopathology of psychosis. (Positive, Negative, Cognitive, Speech, Behavior) 2. Identify the disorders in the psychotic disorder's spectrum and their key characteristics. A. Delusional Disorder B. Brief Psychotic Disorder C. Schizophreniform Disorder D. Schizophrenia E. Schizoaffective Disorder F. Shared Psychotic Disorder G. Substance-Induced Psychotic Disorder H. Psychotic Disorder due to Medical Condition  Schizophrenia Spectrum Disorders As one of the most common severe mental disorders, schizophrenia’s fundamental nature remains unclear. Schizophrenia is likely not a single disease but rather a group of disorders with diverse underlying causes. These disorders show considerable variation in clinical presentation, treatment response, and illness progression among patients. For this reason, it is sometimes described as a syndrome or as a group of related disorders, and the DSM-5 refers to it as a "schizophrenia spectrum disorder.“ The signs and symptoms are highly variable, including changes in perception, emotion, cognition, thinking, and behavior. The expression of these symptoms differs across patients and can change over time, yet the effects of the illness are always severe and long-lasting. Diagnosis is based entirely on psychiatric history and mental status examination. No tests are sensitive or specific enough for diagnostic purposes. Most tests are used to rule out other causes of psychosis. Both patients and their families often endure inadequate care and social ostracism due to widespread misunderstandings about the disorder.  Psychosis Psychosis refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality. During an episode of psychosis, a person’s thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not. Key Features That Define the 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) Negative symptoms.  Positive Symptoms People with positive symptoms may look like they “lose touch with reality” Positive symptoms reflect an excess or distortion of the expected function. Positive symptoms draw the most attention so they are easy to spot. Positive symptoms have a greater fluctuation throughout the course of the disorder than other symptoms. Positive symptoms are associated with poor quality of life. The positive symptoms of schizophrenia include: Hallucinations Delusions Disorganized thinking and speech Disorganized behavior (including catatonia) Positive symptoms respond well to most 1st generation (typical) and 2nd generation (atypical) antipsychotic agents.  Positive Symptom: Delusions Delusions are a hallmark of psychosis. Delusions are fixed false beliefs or ideas that aren’t based on reality but are held with strong conviction; even when presented with evidence, they are untrue. Can occur with or without other psychotic symptoms. Persecutory: Belief that one is being conspired against or threatened by others, including but not limited to individuals, organizations (such as the FBI), religious figures, or extraterrestrials. Reference: Belief that actions or remarks of others, or external events, have a significant personal and often private meaning for the patient. Grandiose: Belief that one has extraordinary powers, gifts, or abilities that are clearly exaggerated and often bizarre. Erotomaniac: Individual believes falsely that another person is in love with him/her Nihilistic: A nihilistic delusion is a false belief that something, including oneself or the world, does not exist or has lost all meaning. Control: Belief that one’s thoughts, feelings, or actions are being controlled or actively manipulated by outside forces or agencies. Guilt: Belief that one has committed a terrible act or crime. Often, there is also the belief that transgressions will lead to impossibly terrible outcomes, and that they are deserving of punishment. Somatic: Belief that one is carrying a severe disease or other malfunction not supported by medical evidence; often bizarre and attributed to outside forces. Celotypical: The central theme of the individual’s delusion is that the lover is unfaithful. Religious: A religious delusion is a false and firmly held belief related to religious or spiritual themes.  Positive Symptoms: Delusions. Delusions can be classified into Non-Bizarre & Bizarre. Non-Bizarre Delusions Bizarre Delusions Plausible Implausible Do derive from ordinary life experiences Do not derive from ordinary life experiences Something that can happen in real life “somehow” Bizarre delusions will be expressed as a loss of control over the (Cheating, hacking, but in the patient it’s still a delusional idea mind or body. not being able to be put into reality despite having evidence to prove the contrary). These include: E.g: Belief that one is under surveillance by the police, despite Thought Withdrawal: Belief that some outside force has removed lack of convincing evidence. one’s thoughts. Delusional Disorder predominantly has Non-Bizarre Thought Insertion: Belief that one’s own thoughts have been put Delusions. into one’s mind by an outside agency. Thought Broadcasting: Belief that one’s thoughts can be read or heard by others via telepathy or broadcasting. Delusions of control: Belief one’s body or actions are being acted on or manipulated by some outside force. E.g: An outside force has removed his external or internal organs and replaced them with someone else’s organs without leaving any wounds or scars  Positive Symptoms: Hallucinations Hallucinations: Perception-like experiences that occur without an external stimulus. Auditory Hallucination: Visual Hallucinations: Command Hallucination: Involve the perception of visual Experienced as voices. Whether familiar or unfamiliar. Subtype of auditory stimuli that are not present in hallucination that instructs a reality seeing objects or Are perceived as distinct from patient to act in specific ways. scenes that do not actually the individual’s own thoughts exist. Olfactory Hallucinations: Gustatory Hallucinations: Also called Phantosmia. Tactile Hallucinations: Also called Phantogeusia. Sensations of smelling Sensation of touch in the absence of physical stimulus. Taste sensation without something that does not exist stimulus. in the environment Proprioceptive Hallucinations: Presence Hallucinations: Perceptual distortion wherein Perception that an individual is individuals perceive accompanied by another movements of their body, such presence in the room or as sensations of flying or positioned closely behind them, floating, despite the absence despite the absence of any of corresponding physical actual external entity. motion.  Negative Symptoms Are also called deficit symptoms. Negative Symptoms are characterized by the reduction of expected functions related to motivation, interest, and expressive functions. Are among the most common first symptoms to present in schizophrenia and can form part of a prodrome before the first acute psychotic episode. Can persist between psychotic episodes, affecting social and occupational functioning. Have been more directly linked to poor quality of life than positive symptoms and their severity determines a patient’s ability to live independently, re- enter the workplace, or maintain stable social relationships. The negative symptoms of schizophrenia include: Alogia: Affective Flattening: Decrease in the production and Absence of outward emotional reaction fluency of spontaneous speech (but Anhedonia: to stimuli. not refusal to speak), which is believed There is a decrease in or absence of to reflect poverty of thought. Diminished or absent capacity to spontaneous movement, expressive experience pleasure Abnormalities may also include gestures, eye contact, shifts in vocal prolonged pauses before answering inflections questions Negative symptoms respond better to 2nd generation (atypical) Avolition than to 1st generation Attention deficits: Asociality Lack of motivation for initiating or (typical) completing tasks, reflective of a loss Inability to maintain engagement in a antipsychotics. Social Withdrawal of drive and of interest in one’s goal-directed activity or task surroundings  Cognitive Symptoms Cognitive Impairment Associated with Schizophrenia (CIAS) affects 85% of patients. CIAS often present early in the disease course. CIAS often appears independently of positive symptoms; even when positive symptoms are absent, cognitive symptoms persist. CIAS may contribute to poor treatment adherence, which can result in relapse or rehospitalization. CIAS predicts a reduction in real-world functioning as it impacts: Quality of Life. Relationships. Employment. Adherence to treatment. Social functioning. Daily Life, (e.g, self-care, cooking) The cognitive symptoms of schizophrenia include: Impaired Impaired Impaired Memory Attention Learning Impaired Executive Functioning Impaired (planning, problem Comprehension solving)  Disorganized Thinking (Disorganized Speech) Disorganized speech is also known as formal thought disorder since language is the primary way to detect changes in your thought patterns. Changes in thought processes impact the way they form their ideas and express them. Disorganized thinking, is usually deduced from the individual's speech patterns. The speech of the patient is filled with run-on sentences, jumbled or incoherent words, words or concepts that do not go together, or awkward phrasings. When this happens the patient speaking is often difficult to follow or understand. These abnormal features of speech are most associated with schizophrenia but are also seen in affective psychoses, non-psychotic illness, substance intoxication, and “organic” brain disorders. Less severe disorganized thinking or speech may occur during the prodromal and residual periods of schizophrenia.  Disorganized Speech Tangentiality: Circumstantiality: Speech that begins in a goal-directed Derailment: manner but deviates gradually and Speech that is goal-directed but consistently such that answers to Speech that begins in a goal-directed excessive in unneeded detail. questions are not reached. manner, but topics shift rapidly Questions are eventually answered; between sentences with no logical however, direct answers are difficult to New topics arise from the topic connection to the topic previously come by. previously under discussion, so an under discussion. association between thoughts can be appreciated. Illogicality: Concrete speech: Incoherence: Speech that is goal-directed but gives Speech that reflects an inability to Incomprehensible speech due to illogical responses to logical use abstract thinking, which may loss of logical connections between questions, or bases assertions on bring about literal interpretations of words, phrases, and sentences, the premises that have no logical or proverbs during mental status extreme form of which is termed word coherent basis. examination. salad. Neologism: Clanging: Thought blocking: Use of nonsensical words, often as a Words are used based on how they Sudden and involuntary interruption combination of parts of two or more sound rather than what they mean. in the progress of speech or thought. different words.  Disorganized Speech Verbigeration: Mutism: Constant or obsessive Absent or minimal repetition of verbal responses meaningless words or phrases. Echolalia: Perseveration: Unsolicited repetition Repeatedly returns of vocalizations made to the same topic by another person.  Disorganized Behavior Unprovoked Unprovoked outbursts of outbursts of laughter hyperactive, agitated, or other emotions or violent behavior Severe neglect of Inappropriate social hygiene or behaviors bizarreness of choice in clothing and general appearance Disorganized Behavior - Catatonia Catatonic behavior is characterized by a notable reduction in reactivity to the environment. This can involve resisting instructions (negativism), maintaining a rigid or inappropriate posture, or experiencing a complete lack of verbal and motor responses (mutism and stupor). Catatonic behavior may also include purposeless and excessive motor activity without an obvious cause (catatonic excitement), along with features like repeated stereotyped movements, staring, grimacing, and echoing of speech. While historically linked to schizophrenia, catatonic symptoms are nonspecific and can occur in other mental disorders (e.g., bipolar or depressive disorders with catatonia) and medical conditions (catatonic disorder due to another medical condition).  Schizophrenia Schizophrenia is one of the most complex psychiatric disorders which is ranked among the top 10 illnesses contributing to the global burden of disease, per the World Health Organization (WHO). The incidence of schizophrenia varies widely around 4-5 per 1,000 people or 8 to 43 cases per 100,000) Schizophrenia is slightly more common in males, with a male-to-female risk ratio of 1.4. Men typically experience earlier onset, Women typically develop schizophrenia with usually between ages 18 and 25, and are onset usually between ages 25 and 35, and a more often diagnosed in adolescence or second peak in onset after age 45, when the early adulthood. incidence shifts to a 2:1 female-to-male ratio. Onset before age 10 is rare and often linked A later onset is associated with better to severe symptoms. outcomes. Earlier onset in general is associated with a poorer long-term prognosis.  Schizophrenia Etiopathophysiology: Initially, Kraepelin proposed a biological basis for schizophrenia, though no specific abnormality was identified at the time. Later, theories shifted to environmental influences, particularly family dynamics, though these were not found to be causal. Today, schizophrenia is understood as a brain disease with complex, multifactorial origins, likely representing a group of related disorders. Family interactions are now seen as factors that may influence stress and coping, affecting the illness's course rather than causing it. Multiple hypotheses have been proposed. The etiology and the pathophysiology of Genetic: Monozygotic twins have a greater risk than dizygotic twins to develop schizophrenia. schizophrenia is still unknown. Viral: Those born in winter and early spring are at risk due to seasonal viral infections. Social: ❖ Downward drift theory: Proposes that the clinical demands of such severe mental health disorders lead to a decline in socioeconomic status ❖ Social causation theory: Suggests that people with severe psychotic disorders are more likely to live in socioeconomically deprived conditions. Neurochemical/biochemical: Dopaminergic. Serotoninergic. GABAergic. Glutamatergic. Cannabinoid. Risk Factors Prenatal Paternal age > 50 at birth Maternal malnutrition Maternal infection: influenza Maternal stress Perinatal Obstetric complications Postnatal Low birth weight Childhood Trauma CNS infections Adolescence Cannabis Use Stimulant Use  Hypothesis Glutamatergic Hypothesis Serotoninergic Hypothesis Suggests that reduced glutamate activity, This theory linked schizophrenia to abnormal particularly involving NMDA receptors, is linked serotonergic activity, influenced by to schizophrenia. hallucinogens like LSD that act on 5-HT NMDA receptor antagonists can mimic receptors. schizophrenia-like symptoms, generating Certain antipsychotics, such as clozapine and both positive and negative symptoms. olanzapine, which block 5-HT2A receptors, may Recent research indicates that the issue may reduce symptoms without causing involve NMDA receptor trafficking and extrapyramidal side effects. signaling rather than simply a decrease in receptor expression. The GABAergic Hypothesis Cannabinoid Hypothesis Dopamine hypothesis Suggests that a deficiency in GABA, the main Involves both exogenous cannabinoids (like Suggests that excessive dopamine (DA) activity in limbic regions, inhibitory neurotransmitter, contributes to the cannabis) that can induce psychotic like the nucleus accumbens (Mesolimbic Pathway) underlies disorder. symptoms and endogenous cannabinoid positive symptoms, as supported by amphetamine-induced psychosis system abnormalities in schizophrenia, and the effectiveness of D2-blocking antipsychotics. PET studies show Reduced GAD67 mRNA in key brain areas and deficits in parvalbumin-containing GABA including altered levels of anandamide, increased presynaptic DA in acutely psychotic patients. interneurons may lead to abnormal pyramidal which are linked to psychotic symptoms. Negative symptoms and cognitive issues may result from reduced neuron activity and impaired cortical DA in the prefrontal cortex (prefrontal hypodopaminergia) synchronization. (Mesocortical Pathway) However, limitations of the hypothesis include the involvement of other neurotransmitters, inconsistent findings on DA receptor density, and inconclusive evidence of increased D2 receptors. Thus, while DA dysfunction is significant, schizophrenia likely involves multiple neurotransmitter systems. Table taken from Kaplan Medical - Preclinical Behavioral Science and Social Sciences Review 2023 For USMLE Step 1 and COMLEX-USA Level 1-Kaplan Test Prep (2023)  Schizophrenia Duration of active psychotic symptoms for at least 1 month, or for a shorter duration if successfully treated. Total duration of illness for at least 6 months, including prodrome, acute phase, and residual symptoms. Cognitive impairment and disorganization characterized by disorganized, illogical, loosely associated or bizarre speech, or by inappropriate or bizarre behaviors. The above symptoms are idiopathic in nature—that is, they are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Dysfunction in one or more life domains as a result of the above signs or symptoms. Chapter 13-04 Diseases & Pathophysiology in Psychiatry, Huppert LA, Dyster TG. Huppert’s Notes: Pathophysiology and Clinical Pearls for Internal Medicine; 2021 Copyright © 2023 McGraw-Hill Education. All rights reserved Prognosis Individuals with schizophrenia have a life expectancy 15–25 years shorter than the general population, largely due to elevated risks of metabolic, cardiovascular, respiratory, and infectious diseases. Sedentary lifestyle, substance abuse, high smoking rates (60–80%), and antipsychotic side effects like weight gain and glucose elevation further exacerbate health risks. >90% of patients smoke (nicotine may reduce positive symptoms and improve some cognitive impairments). Roughly 75% of schizophrenia-related deaths result from coronary heart disease. Higher suicide rates (10–13%) and accidents also contribute to early mortality, especially among young males, those in the early stages of illness, and those facing social isolation, stigma, or treatment non- adherence. Despite these needs, people with schizophrenia often underutilize healthcare due to barriers like cognitive impairment, stigma, poverty, and comorbidities, which worsen the life expectancy gap with the general population.  Delusional Disorder The diagnosis of delusional disorder is made when a person exhibits one or more delusions of at least 1 month’s duration that cannot be attributed to other psychiatric disorders. The delusions are often non-bizarre (meaning that the delusions are about situations that can occur in real life such as being followed, infected, loved at a distance, and so on) That is, they usually have to do with phenomena that, although not real, are nonetheless possible. The most remarkable feature of patients with delusional disorder is that the mental status examination shows them to be quite normal except for a markedly abnormal delusional system. While delusional disorder is usually stable, a portion of cases may progress to schizophrenia.  Delusional Disorder Types of Delusional Disorder: Erotomanic: Belief that someone is in love with the individual. Grandiose: Conviction of possessing a special talent or discovery. Jealous: Belief in a partner's infidelity. Persecutory: Belief of being targeted, harassed, or conspired against. Somatic: Delusions about bodily functions or sensations. Mixed: No single theme predominates. Unspecified: Delusions that don’t fit specific categories. taken from Wikimedia Commons  Brief Psychotic Disorder Brief psychotic disorder is defined as a psychotic condition that involves the sudden onset of psychotic symptoms, which lasts 1 day or more but less than 1 month. Remission is full, and the individual returns to the premorbid level of functioning. Brief psychotic disorder is an acute and transient psychotic syndrome. The disorder occurs more often among younger patients (20s and 30s) The cause of the disorder is not known; however, it is common in patients with personality disorders. Persons who have gone through major psychosocial stressors may be at greater risk for subsequent brief psychotic disorder. Characteristic symptoms in brief psychotic disorder include emotional volatility, strange or bizarre behavior, screaming or muteness, and impaired memory of recent events. Schizophreniform Disorder The symptoms of schizophreniform are similar to those of schizophrenia. However, with schizophreniform disorder, the symptoms are short term, lasting at least 1 month but less than 6 months. By definition, patients with schizophreniform disorder have the symptoms for at least a month and return to their baseline state within 6 months. About one-third of individuals with an initial diagnosis of schizophreniform disorder (provisional) recover within 6 months and schizophreniform disorder is their final diagnosis. The majority of the remaining two-thirds of individuals will eventually develop schizophrenia or schizoaffective disorder.  Schizoaffective disorder has features of both schizophrenia Schizoaffective Disorder and mood disorders. Mood Symptoms are present majority of the time during the illness. There is also a 2-week period of psychotic symptoms without mood symptoms.  Substance Induced Psychotic Disorder Substances that generate psychosis: Alcohol Is diagnosed when delusions or hallucinations develop during or soon after substance intoxication, withdrawal, or Cannabis exposure to a medication known to produce such Phenyclidine symptoms. Hallucinogens This disorder is confirmed by evidence from the patient's history, physical examination, or laboratory findings. Inhalants The symptoms must not be explained by an independent Sedative, hypnotic, anxiolytic psychotic disorder, which could be indicated if symptoms Amphetamine-type substances (or other stimulants) precede substance use or persist for about a month after cessation of substance use. Cocaine The condition should not occur exclusively during delirium and must cause significant distress or impairment in social, occupational, or other important areas of functioning. This diagnosis is warranted when the psychotic symptoms dominate the clinical picture and are severe enough to necessitate clinical attention. Psychotic Disorder due to Medical Condition Is characterized by prominent hallucinations or delusions directly resulting from a medical condition. This diagnosis is supported by evidence from the patient's history, physical examination, or laboratory findings, indicating the psychotic symptoms are a direct pathophysiological consequence of the medical condition. Another mental disorder cannot better explain the disturbance and does not occur exclusively during delirium. It must cause significant distress or impairment in social, occupational, or other important areas of functioning. The diagnosis depends on the individual's clinical condition, with diagnostic tests tailored to identify the underlying medical cause. Other Psychotic Disorders: Shared Psychotic Disorder Also known as "shared psychosis“ The most common form (and the one recognized in DSM-5) is folie á deux. This disorder involves the transfer of delusions from one person (the "primary case") to another (the "secondary case"). Typically, both individuals have a close, long-term relationship and live together in relative social isolation. The primary case is often chronically ill and holds a dominant role in the relationship, influencing the more suggestible secondary case to adopt the delusion. The secondary case is usually more passive, less confident, or more gullible. Separation of the pair can sometimes lead to the secondary person abandoning the delusion, though this is not always the case. Other forms of shared psychosis exist, such as folie simultanée, where two individuals develop the same delusion at the same time. In rare cases, more than two people may be involved (e.g., folie à trois, quatre, cinq, or folie à famille). Shared psychosis most commonly occurs in family relationships, such as sister–sister, husband–wife, and mother–child pairs, with almost all cases involving members of the same family. The Exam  References Radhakrishnan R, & Ganesh S, & Meltzer H.Y., & Bobo W.V., & Heckers S.H., & Fatemi S, & D’Souza D (2024). Schizophrenia. Ebert M.H., & Martin P.R., & McVoy M, & Ronis R.J., & Weissman S.H.(Eds.), Current Diagnosis & Treatment: Psychiatry, 4th Edition. McGraw Hill. https://bibliodig.uag.mx:2091/content.aspx?bookid=3507&sectionid=289853094 Schizophrenia Spectrum and Other Psychotic Disorders (2022) in Diagnostic and statistical manual of mental disorders: DSM-5-TR. Washington, DC: American Psychiatric Association Publishing, pp. 101–139. Boland, R.J. et al. (2022) Chapter V Schizophrenia Spectrum and Other Psychotic Disorders, in Kaplan & Sadock’s Synopsis of Psychiatry. Philadelphia: Wolters Kluwer, pp. 995–1091. Le, T. et al. (2023) Psychiatry - Psychiatry Pathology Section III, in First aid for the USMLE step 1 2023. New York: McGraw Hill, pp. 578. Reus V.I. (2022). Psychiatric disorders. Loscalzo J, & Fauci A, & Kasper D, & Hauser S, & Longo D, & Jameson J(Eds.), Harrison's Principles of Internal Medicine, 21e. McGraw Hill. https://bibliodig.uag.mx:2091/content.aspx?bookid=3095&sectionid=265468363 Diseases & pathophysiology in psychiatry. Huppert L.A., & Dyster T.G.(Eds.), (2021). Huppert’s Notes: Pathophysiology and Clinical Pearls for Internal Medicine. McGraw Hill. https://bibliodig.uag.mx:2091/content.aspx?bookid=3072&sectionid=257403836