Assessing Psychotic Disorders

Screening Questions

Have you had any experiences like dreaming when you’re awake?
Have you had any strange or odd experiences lately that you can’t explain?
Do you ever hear or see things that other people can’t hear or see?
Do you ever feel that people are bothering you or trying to harm you?
Does it seem that strangers look at you a lot or make comments about you?

Recommended time: 2 minutes for screening; 5 to 10 minutes for probing if screen is positive.

A body seriously out of equilibrium, either with itself or with its environment, perishes outright. Not so a mind. Madness and suffering can set themselves no limit.

–George Santayana

The first important point for novice interviewers is that psychosis and schizophrenia are not interchangeable. Psychosis is a general term referring to disordered processing of thought and impaired grasp of reality. As such, psychosis can occur as a part of many psychiatric syndromes other than schizophrenia, including

Depression
Mania
Overwhelming stress (brief reactive psychosis)
Dissociative disorders
Dementia and delirium
Substance intoxication or withdrawal
Personality disorders (PDs)

In terms of the rapid diagnostic evaluation, this means that you must ask every patient you interview, not only those whom you suspect of having schizophrenia, screening questions about psychotic ideation.

The second useful point, related to the first, is that there are two types of psychotic patients: (a) those who are obviously psychotic and (b) those whose psychoses are not obvious. In most outpatient settings, the typical patient will not appear psychotic at first glance. He will speak coherently, will not volunteer any delusional material, and will not appear to be hallucinating. However, many of these patients will have a subtle or hidden psychosis that will require a number of screening questions to uncover. These screening questions and techniques are described in the first part of this chapter.

On the other hand, patients who are obviously psychotic don’t require subtle screening questions. Instead, you will ask probing questions to better understand the precise type of psychosis with which you are dealing. In the second part of this chapter, I define the more common thought disorders and then describe strategies for ascertaining which are present in a particular patient.

GENERAL SCREENING QUESTIONS

When you are interviewing a patient who speaks coherently and has a good grasp of reality, it is tempting to skip questions regarding psychosis. This is a mistake, because hidden psychosis is common, especially in major depression, dementia, and substance abuse. In addition, a nonpsychotic patient may have a history of psychosis, which in turn may influence your diagnosis or treatment.

Two good initial questions are as follows:

Have you had any experiences like dreaming when you’re awake?

Have you had any strange or odd experiences lately that you can’t explain?

Patients who answer “no” to both of these questions may still be psychotic, and if you suspect this, you should follow up with

Do you ever hear or see things that other people can’t hear or see?

This asks directly about auditory and visual hallucinations but is more graceful than the old standby, “Do you hear voices?”

TIP

Not all people who hear voices have a psychiatric syndrome. Epidemiological research has documented that 3% to 4% of people in the general population report a history of auditory hallucinations (AHs), and less than one-half of them meet criteria for schizophrenia or dissociative disorder. In one study comparing patient with nonpatient “voice hearers,” the nonpatients often reported the onset of AHs before age 12, and 93% of them thought that the voices were predominantly positive (Honig et al. 1998).

Have people been harassing you or trying to harm you?

This question screens for paranoid ideation in a nonjudgmental way. You are not asking your patient if she is paranoid, but rather whether she feels others are wronging her. A subtly paranoid patient may welcome this chance to vent her complaints about the Federal Bureau of Investigation’s (FBI’s) wire-tapping activities.

Does it seem that strangers look at you a lot or make comments about you?

This is a screen for ideas of reference, a common psychotic delusion in which the patient believes that apparently neutral events have a special significance or communication for her. Ideas of reference can be very subtle and difficult to diagnose, as the following vignette illustrates.

CLINICAL VIGNETTE

An intern was admitting a 63-year-old widowed woman with major depression. The patient had become increasingly depressed since her husband died 1 year earlier, and she had not responded to antidepressants thus far, prompting an admission for more intensive diagnostic evaluation and treatment. After establishing criteria for major depression, the intern asked her screening questions for psychotic ideation:

Interviewer: Do you ever feel that people you don’t know are looking at you or making comments about you?

Patient: No.

Interviewer: Do you ever hear voices or see things that other people can’t see?

Patient: No.

Interviewer: Has anyone been bothering you or harassing you?

Patient: Just the kids in the neighborhood.

Interviewer: What have they been doing?

Patient: What kids do, yelling and carrying on.

At this point, the intern was tempted to drop this topic and move on to another section of the interview, but she had a vague sense that there was something more to this story than the “carrying on” of neighborhood kids.

Interviewer: What sorts of things have the kids been yelling?

Patient: Saying bad things about me.

Interviewer: What sorts of things?

Patient: Oh, that I’m a prostitute. That I run a whorehouse. They’re yelling it day and night.

As it turned out, the patient had major depression with psychotic features (AHs and ideas of reference) and required combination therapy with an antidepressant and a neuroleptic before she improved.

Of course, you can use many other symptoms as springboards for asking about psychosis, including the following:

Anxiety: Has your anxiety gotten to the point where your imagination is working in overdrive, so that you hear voices or think people are trying to harm you?
Substance abuse: Have these drugs ever caused your mind to play tricks on you, such as…?
Dementia: When you misplace things around the house, do you ever suspect that someone’s been stealing them?

PROBING QUESTIONS: HOW TO DIAGNOSE SCHIZOPHRENIA

There is both good news and bad news about diagnosing schizophrenia. The good news is that it is fairly easy; the bad news is that we have made it seem complicated by creating a plethora of colorful, though confusing, terms for describing psychosis. To illustrate, here is a partial list of terms in current use:

Tangentiality
Circumstantiality
Distractibility
Derailment
Looseness of associations (LOAs)
Disjointed speech
Flight of ideas
Pressure of speech
Racing thoughts
Word salad
Incoherence
Loss of goal
Illogical thinking
Rambling
Thought blocking
Poverty of speech
Poverty of thought
Poverty of content
Non sequiturs
Perseveration
Clanging
Neologism
Paraphasias
Echolalia
Stilted speech
Self-reference
Persecutory (paranoid) delusions
Delusion of jealousy
Erotomania
Delusion of control
Delusion of guilt or sin
Delusion of grandiosity
Delusion of mind reading
Ideas of reference
Delusion of replacement
Nihilistic delusion
Somatic delusion
Thought broadcasting
Thought insertion
Thought withdrawal
Magical thinking
Poor reality testing
Attending to internal stimuli

To begin to simplify this semantic onslaught, it’s helpful to review the basic criteria for schizophrenia.

SCHIZOPHRENIA

The DSM-IV-TR criteria for schizophrenia are listed in Table 27.1.

Delusions (Disorders of Thought Content)

A common and useful distinction is made between TC and TP. Both TC and TP can be impaired in psychosis. Impaired TP is covered under the speech disorganization criterion for schizophrenia later in this chapter. Impaired TC refers to delusional thinking. A delusion is a belief about the world that most people would agree is impossible. Most delusions fit into two broad categories: paranoid delusions and grandiose delusions.

Paranoid Delusions

According to a World Health Organization study of 811 individuals with schizophrenia worldwide (McKenna 1994), paranoia was the most common single delusion, affecting 60% of patients. Paranoid patients believe that people are harassing them, chasing them, spying on them, spreading rumors
about them, or trying to kill them. Large organizations are frequently thought to be involved, such as the FBI, the Central Intelligence Agency, or the Mafia. For example, a young man believed that his wife was an undercover FBI agent determined to kill him for having “blown her cover.”

TABLE 27.1. DSM-IV-TR criteria for schizophrenia

Requires two symptoms for 1 month, plus 5 months of prodromal or residual symptoms.
Mnemonic: Delusions Herald Schizophrenic’s Bad News
	Delusions
	Hallucinations
	Speech disorganization
	Behavior disorganization
	Negative symptoms
Adapted from American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text revision. Washington, DC: American Psychiatric Association.