Survey of Modern Psychology
Schizophrenia and Psychotic Disorders
What is Schizophrenia?
SCHIZOPHRENIA IS
NOT MULTIPLE
PERSONALITIES!
Definitions
• “Positive” symptoms refer to presence of
abnormal behavior, thoughts, beliefs, etc.
• “Negative” symptoms refer to absence of
normal behavior (e.g., responsiveness to
environment)
Definitions
• Hallucination
– A distortion in perception that can occur through any of
the senses
• Auditory, visual, olfactory, gustatory, and tactile
• Auditory hallucinations are the most common
• Delusion
– Erroneous beliefs that usually involve a misinterpretation
of perceptions or experiences
– It can be difficult at times to differentiate a strongly held
belief from a delusion. The determination depends largely
on the degree of conviction with which the belief is held
despite clear evidence to the contrary
Psychotic Disorders
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Schizophrenia
Schizophreniform Disorder
Schizoaffective Disorder
Delusional Disorder
Brief Psychotic Disorder
Shared Psychotic Disorder (Folie à Deux)
Schizophrenia
A. Characteristic symptoms: Two (or more) of the following,
each present for a significant portion of time during a 1month period (or less if successfully treated):
1 Delusions
2 Hallucinations
3 Disorganized speech (e.g., frequent derailment or incoherence)
4 Grossly disorganized or catatonic behavior
5 Negative symptoms, i.e., affective flattening, alogia, or avolition
Note: Only one Criterion A symptom is required if delusions are
bizarre or hallucinations consist of a voice keeping up a running
commentary on the person’s behavior or thoughts, or two or
more voices conversing with each other
Schizophrenia
B. Social/occupational dysfunction: for a
significant portion of the time since the onset
of the disturbance, one or more major areas
of functioning such as work, interpersonal
relations, or self-care are markedly below the
level achieved prior to the onset (or when the
onset is in childhood or adolescence, failure
to achieve expected level of interpersonal,
academic, or occupational achievement)
Schizophrenia
C. Duration: 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 two or more symptoms
listed in Criterion A present in an attenuated form (e.g.,
odd beliefs, unusual perceptual experiences)
Schizophrenia
D. Schizoaffective and Mood Disorder exclusion:
Schizoaffective Disorder and Mood Disorder With
Psychotic Features have been ruled out because either
(1) no Major Depressive, Manic, or Mixed Episodes have
occurred concurrently with the active-phase symptoms;
or (2) if mood episodes have occurred during activephase symptoms, their total duration has been brief
relative to the duration of the active and residual
periods
Schizophrenia
E. Substance/general medical condition
exclusion: The disturbance is not due to the
direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a
general medical condition
Schizophrenia
F. Relationship to a Pervasive Developmental
Disorder: If there is a history of Autistic
Disorder or another Pervasive Developmental
Disorder, the additional diagnosis of
Schizophrenia is made only if prominent
delusions or hallucinations are also present
for at least a month (or less if successfully
treated)
Schizophreniform Disorder
A. Criteria A, D, and E of Schizophrenia are met*
B. An episode of the disorder (including prodromal, active,
and residual phases) 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”)
*This refers to symptoms and the exclusion of other mental
disorders, medical conditions, or substance use
Schizophreniform Disorder
Specify if:
Without Good Prognostic Features
With Good Prognostic Features: as evidenced by two (or more) of the
following:
1. Onset of prominent psychotic symptoms within 4 weeks of the first
noticeable change in usual behavior or functioning
2. Confusion or perplexity at the height of the psychotic episode
3. Good premorbid social and occupational functioning
4. Absence of blunted or flat affect
Schizophreniform Disorder: Notes
• Much less prevalent than Schizophrenia
• Does not require impairment in functioning
(though most individuals do experience
impairment)
Schizophrenia Subtypes
The subtypes of Schizophrenia are defined by the predominant
symptomatology at the time of evaluation
• Paranoid Type
A. Preoccupation with one or more delusions or frequent
auditory hallucinations
B. None of the following is prominent: disorganized speech,
disorganized or catatonic behavior, or flat or inappropriate
affect
Schizophrenia Subtypes - Paranoid
•
Delusions are typically persecutory or grandiose, or both
– Delusions with other themes (e.g., jealousy, religiosity, or
somatization) may also occur
• Delusions and hallucinations are usually organized around a
coherent theme, and hallucinations are related to the
delusions
• Associated features include anxiety, anger, aloofness, and
argumentativeness.
• The individual may have a superior and patronizing manner
and either a stilted, formal quality or extreme intensity in
interpersonal interactions.
Schizophrenia Subtypes - Paranoid
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Persecutory delusions may predispose the individual to
suicidal behavior; the combination of persecutory and
grandiose delusions with anger may predispose the
individual to violence
Onset tends to be later in life and more stable
Usually show little or no impairment on cognitive
testing
The prognosis may be better than other types of
schizophrenia
Schizophrenia Subtypes
• Disorganized Type
A. All of the following are prominent:
1) Disorganized speech
2) Disorganized behavior
3) Flat or inappropriate affect
B. The criteria are not met for Catatonic Type
Schizophrenia Subtypes - Disorganized
• The disorganized speech may be accompanied
by silliness and laughter that are not closely
related to the content of the speech
• The behavioral disorganization (i.e., lack of
goal orientation) may lead to severe
disruption in the ability to perform activities
of daily living (e.g., showering, dressing, or
preparing meals)
Schizophrenia Subtypes - Disorganized
• If present, delusions and hallucinations are not
organized around a coherent theme
• Associated features include grimacing,
mannerisms, and other oddities of behavior
• There is often impaired performance on cognitive
tests
• Usually associated with poor pre-morbid
functioning, early and insidious onset, and a
continuous course without significant remissions
Schizophrenia Subtypes - Catatonic
A type of Schizophrenia in which the clinical picture is dominated
by at least two of the following:
1. Motoric immobility as evidenced by catalepsy (including
waxy flexibility) or stupor
2. Excessive motor activity (that is apparently purposeless and
not influenced by external stimuli)
3. Extreme negativism (an apparently motiveless resistance to
all instructions or maintenance of a rigid posture against
attempts to be moved) or mutism
4. Peculiarities of voluntary movement as evinced by posturing
(voluntary assumption of inappropriate or bizarre postures),
stereotyped movements, prominent mannerisms, or
prominent grimacing
5. Echolalia or echopraxia
Schizophrenia Subtypes - Catatonic
• Catalepsy: “waxy flexibility”
• Echolalia: senseless repetition of a word or
phrase that was just spoken by another
rperson
• Echopraxia: repetitive imitation of the
movements of another person
• There may be increased risk for harm to the
self or others
– self harm risks particularly include malnutrition,
exhaustion, and self-inflicted injury
Schizophrenia
• Undifferentiated Type
– A type of Schizophrenia in which symptoms that meet Criterion
A are present, but the criteria are not met for the Paranoid,
Disorganized, or Catatonic Type
• Residual Type
A. Absence of prominent delusions, hallucinations,
disorganized speech, and grossly disorganized or catatonic
behavior
B. There is continuing evidence of the disturbance, as
indicated by the presence of negative symptoms or two or
more symptoms listed in Criterion A for Schizophrenia,
present in an attenuated form (e.g., odd beliefs, unusual
perceptive experiences)
Common Types of Delusions
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Persecutory
Referential
Somatic
Religious
Grandiose
Thought broadcasting
Thought insertion or withdrawal
Types of Delusions: Persecutory
• These are the most common type of delusion
• The person believes that he or she is being
tormented, followed, tricked, spied on, or
ridiculed
• Examples: DE, LG
Types of Delusions: Referential
• Also very common
• The person believes
that certain gestures,
comments, passages
from books,
newspapers, song
lyrics, or other
environmental cues
are specifically
directed at him or her
Types of Delusions: Somatic
• A delusion that one’s body has been changed
or altered
• Example: LP
Types of Delusions: Religious
• A delusion with religious or spiritual content
• It does not match the religion’s actual beliefs
or tenets
Types of Delusions: Grandiose
• An individual exaggerates his or her sense of selfimportance and is convinced that he or she has
special powers, talents, or abilities
• Sometimes, the individual may actually believe
that he or she is a famous person
• More commonly, a person with this delusion
believes he or she has accomplished some great
achievement for which they have not received
sufficient recognition
• Example: LG
Types of Delusions:
Thought Broadcasting
• A belief that one’s thoughts can be heard
aloud
• Example: RO
Types of Delusions:
Thought Insertion & Thought
Withdrawal
• The belief that others can put thoughts in, or
remove thoughts from, the person’s brain
Delusions
• A delusion is considered bizarre if it is
completely impossible and unrealistic
• A non-bizarre delusion is still false, but could
occur
– Ex. belief that one is being watched by the police
Schizophrenia - Demographics
• In the US and UK non-White people are more often
diagnosed with schizophrenia
– It is unclear whether there is a a true difference in the
rates of Schizophrenia, or only in diagnosis
• People in non-industrialized nations tend to have a
better outcome than people in industrialized nations
• Women are more likely to have positive symptoms,
men are more likely to have negative symptoms
• There is a slightly higher incidence of Schizophrenia in
men than women
• Women tend to have a short term better outcome
than men, but over time it evens out
Schizophrenia - Demographics
• Prevalence among adults is .5% - 1.5%
• A later age of onset is associated with a better
prognosis
• Individuals with an earlier onset tend to have
poorer premorbid adjustment, lower
educational achievement, more evidence of
brain abnormalities, and more cognitive
impairment
Schizophrenia - Demographics
• Men:
– Median age of onset: early to mid 20s
– Modal age of onset: between 18 and 25
• Women:
– Median age of onset: late 20s
– Bimodal age of onset:
• Between 25 and 35
• Over 40
Schizophrenia: Associated Findings
• The lateral ventricles are consistently found to
be larger among people with Schizophrenia
Schizophrenia: Associated Findings
• Decreased volume of the temporal lobe
• Increased size of the basal ganglia (though this
may be due to the medications used to treat
Schizophrenia rather than the disorder itself)
• Decreased blood flow in the front of the brain
Schizophrenia:
Associated Features and Disorders
• A majority of people with Schizophrenia have poor insight
– This makes noncompliance with treatment and therefore
relapse more likely
• Anxiety and phobias are common
• Approximately 10% of Schizophrenics commit suicide
– 20% - 40% make at least one attempt
– Suicide is particularly common immediately after a psychotic
period
• Schizophrenics overall are not any more prone to violence
than the average person, but it varies by subgroup
– Risks include: noncompliance, male, younger, past history of
violence, substance abuse
Schizophrenia:
Associated Features and Disorders
• Extremely high comorbidity with substance abuse
– 80% - 90% of people with Schizophrenia report being
regular cigarette smokers
• There is a high incidence of Obsessive-Compulsive
Disorder and Panic Disorder among Schizophrenics and
one of these disorders often precedes the diagnosis of
Schizophrenia
– It is unclear whether the disorder is separate
• Other risks include: prenatal exposure to flu, prenatal
exposure to famine, obstetric complications, and CNS
infection in early childhood
Schizophrenia: Treatment
• Antipsychotic medications are the most popular
and effective treatment
– It is generally believed that psychoanalysis should not
be used
• Other forms of therapy/talk therapy may be used
in conjunction with medications to deal with
nonbiological components of the disorder (e.g.,
social training, self-care)
• A longer time between onset of psychosis and
treatment is suggested to be linked to a worse
outcome
Schizophrenia: Treatment
• Approximately 60% of Schizophrenics treated
with medications recover to the point of full
remission
– The other 40% show improvement to varying levels
– Some require chronic hospitalization, others are
functional but continue to have some symptoms
• A 4 – 6 week trial period on a medication is
recommended for most patients to determine
whether a medication is working
Schizophrenia: Treatment
• Medications used for Schizophrenia block
dopamine receptors (dopamine antagonists)
• Newer medications act on both serotonin and
dopamine
• For patients who are noncompliant with
medication, injections are available
– Approximately 40% - 50% become noncompliant
within two years
First Generation Antipsychotic
Medications (Dopamine antagonists)
• These largely act as tranquilizers
• Side effects include: restlessness, tremors, and
Tardive Dyskinesia, and weight gain
• Thorazine is known for causing significant
sedation
– “Thorazine shuffle”
First Generation Antipsychotic
Medications (Dopamine antagonists)
Brand Name
Generic
Mellaril
Thioridazine
Prolixin
Fluphenazine
Serentil
Mesoridazine
Stelazine
Trifluoperazine
Thorazine
Chlorpromazine
Trifalon
Perphenazine
Haldol
Haloperidol
Loxitane
Loxapine
Moban
Molindone
Navane
Thiothixene
Second Generation
Antipsychotics/Atypical Antipsychotics
• Atypical antipsychotics act on serotonin as
well as dopamine
• They are often not as effective as the first
generation antipsychotics, but have fewer side
effects
Second Generation
Antipsychotics/Atypical Antipsychotics
Brand Name
Generic
Clorazil
Clozapine
Risperdal
Risperidone
Seroquel
Quetiapine
Zyprexa
Olanzapine
Tardive Dyskinesia
• Tardive Dyskinesia may develop as a side
effect of antipsychotic medication and can be
permanent
• This was particularly problematic with the
earlier medications
• Tardive Dyskinesia is considered an area for
further study in the DSM-IV-TR
Tardive Dyskinesia
A. Involuntary movements of the tongue, jaw, trunk, or
extremities have developed in association with the use of
neuroleptic medication
B. The involuntary movements are present over a period of at
least 4 weeks and occur in any of the following patterns:
1. Choreiform movements (i.e., rapid, jerky, nonrepetitive)
2. Athetoid movements (i.e., slow, sinuous, continual)
3. Rhythmic movements (i.e., stereotypies)
Tardive Dyskinesia
C. The signs or symptoms in Criteria A and B develop during
exposure to a neuroleptic medication or within 4 weeks of
withdrawal from an oral (or within 8 weeks of withdrawal
from a depot) neuroleptic medication
D. There has been exposure to neuroleptic medication for at
least 3 months (1 month if age 60 or older)
E. The symptoms are not due to a neurological or general
medical condition, ill-fitting dentures, or exposure to other
medications that cause acute reversible dyskinesia. Evidence
that the symptoms are due to one of these etiologies might
include the following: the symptoms precede the exposure
to the neuroleptic medication or unexplained focal
neurological signs are present
F. The symptoms are not better accounted for by a neurolepticinduced acute movement disorder
Tardive Dyskinesia
http://www.youtube.com/watch?v=FUr8ltX
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Schizoaffective Disorder
• An uninterrupted period of illness during which, at some time,
there is a Major Depressive, Manic, or Mixed Episode
concurrent with symptoms that meet Criterion A for
Schizophrenia. In addition, during the same period of illness,
there have been delusions or hallucinations for at least 2
weeks in the absence of prominent mood symptoms
• The minimum amount of time that a Schizoaffective episode
can last is one month (to meet Criterion A for Schizophrenia,
the symptoms must last at least 1 month)
• The mood symptoms must be present for a substantial
portion of the entire period of illness (e.g., Depressive
symptoms lasting for 5 weeks in the course of 4 years of
Schizophrenic symptoms would not apply)
Schizoaffective Disorder
A. An uninterrupted period of illness during which,
at some time, there is either a Major Depressive
Episode, a Manic Episode, or a Mixed Episode
concurrent with symptoms that meet Criterion A
for Schizophrenia
Note: The Major Depressive Episode must include
Criterion A1: depressed mood
B. During the same period of illness, there have
been delusions or hallucinations for at least 2
weeks in the absence of prominent mood
symptoms
Schizoaffective Disorder
C. Symptoms that meet criteria for a mood
episode are present for a substantial portion
of the total duration of the active and
residual periods of the illness
D. The disturbance is not due to the direct
physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general
medical condition
Schizoaffective Disorder: Notes
• Seems to be less common than Schizophrenia
• Younger people are more likely to experience Bipolar
Type, while older adults are more likely to experience
Depressive Type
• Schizoaffective Disorder is more common in women
(mostly because more women experience the
Depressive Type)
• The prognosis may be better for the Bipolar Type
• The prognosis is better if there is a precipitating
event/stressor
• Age of onset is usually early adulthood, but it can
occur any time
Delusional Disorder
A. Nonbizarre delusions (i.e., involving situations
that occur in real life, such as being followed,
poisoned, infected, loved at a distance, or
deceived by spouse or lover, or having a
disease) of at least 1 month's duration
B. Criterion A for Schizophrenia has never been
met. Note: tactile and olfactory hallucinations
may be present in Delusional Disorder if they
are related to the delusional theme
Delusional Disorder
C. Apart from the impact of the delusion(s) or its
ramifications, functioning is not markedly impaired
and behavior is not obviously odd or bizarre
D. If mood episodes have occurred concurrently with
delusions, their total duration has been brief relative
to the duration of the delusional periods
E. The disturbance is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition
Delusional Disorder
Specify type (the following types are assigned based on the predominant
delusional theme
Erotomanic Type: delusions that another person, usually of higher
status, is in love with the individual
Grandiose Type: delusions of inflated worth, power, knowledge,
identity, or special relationship to a deity or famous person
Jealous Type: delusions that the individual’s sexual partner is
unfaithful
Persecutory Type: delusions that the person (or someone to whom
the person is close) is being malevolently treated in some way
Delusional Disorder
Specify type (the following types are assigned based on the predominant
delusional theme
Somatic Type: delusions that the person has
some physical defect or general medical
condition
Mixed Type: delusions characteristic of more
than one of the above types but no one
theme predominates
Unspecified Type
Delusional Disorder: Notes
• Fairly uncommon
– 1% - 2% of inpatients
– About .03% in the total population
• Persecutory delusions are the most common
• When there is a precipitating event or stressor,
the prognosis tends to be better
• Age of onset varies
• Some studies have found a higher incidence in
relatives of Schizophrenics, others have found no
relationship
Brief Psychotic Disorder
A. Presence of one (or more) of the following symptoms:
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 pattern
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
Brief Psychotic Disorder
C.
The disturbance is not better accounted for by a Mood Disorder
With Psychotic Features, Schizoaffective Disorder, or Schizophrenia
and is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition
Specify if:
With Marked Stressor(s) (brief reactive psychosis): if symptoms occur
shortly after and apparently in response to events that, singly or
together, would be markedly stressful to almost anyone in similar
circumstances in the person’s culture
Without Marked Stressor(s): if psychotic symptoms do not occur
shortly after, or are not apparently in response to events that,
singly or together, would be markedly stressful to almost anyone in
similar circumstances in the person’s culture
With Postpartum Onset: if onset is within 4 weeks postpartum
Shared Psychotic Disorder (Folie à
Deux)
A. A delusion develops in an individual in the context of a
close relationship with another person(s) who has an
already-established delusion
B. The delusion is similar in content to that of other
person who already has the established delusion
C. The disturbance is not better accounted for by
another Psychotic Disorder (e.g., Schizophrenia) or a
Mood Disorder With Psychotic Features and is not due
to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medical
condition
Shared Psychotic Disorder (Folie à
Deux)
• The first person is usually schizophrenic
• The people involved usually have had a very
close relationship (e.g., are related by blood or
marriage)
• With separation, the second person’s belief
usually disappears
• Without intervention, it tends to be chronic and
often not come up in clinical settings
• Somewhat more common in women than men