Schizophreniform Disorder
DSM-IV-TR Diagnostic Criteria
Criteria A, D, and E of schizophrenia must be met.
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.”
Specify if:
Without good prognostic features
With good prognostic features: as evidenced by two (or more) of the following:
onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning
confusion or perplexity at the height of the psychotic episode
good premorbid social and occupational functioning
absence of blunted or flat affect
(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000)
Diagnostically, schizophreniform disorder is “positioned” in time between brief psychotic disorder (discussed later in this chapter), which lasts 1 month or less, and schizophrenia (see Chapter 16), which by definition continues beyond 6 months. Although many patients eventually will be shown to have schizophrenia, a small but significant number of patients with persisting psychotic disorders will show complete recovery of their illness. The proportion of recovery is likely to be small, although the exact percentage is unknown. Those who do show recovery typically exhibit characteristics known to predict better outcome in other diagnostic categories (e.g., acute onset, brief prodrome, lack of psychosocial deterioration, and prominent mood symptoms).
Schizophreniform disorder is a heterogeneous category; therefore, in all likelihood, it has several distinct etiologies. Because most patients with this disorder will proceed on to meet diagnostic criteria for schizophrenia, the etiologies will be the same as for that condition, discussed in detail in Chapter 16. Some patients with this disorder appear to recover significantly and thus represent a manifestation that is distinct from typical schizophrenia.
Because schizophreniform disorder is likely to be an etiologically heterogeneous disorder, genetic relationships are unclear. Those persons who proceed on to manifest typical schizophrenia show genetic predispositions that are similar to this condition. Those who recover completely may have increased family histories of both psychotic and affective disorders, especially bipolar disorder.
Patients with schizophreniform disorder exhibit symptoms consistent with Criterion A of schizophrenia (i.e., typically hallucinations; delusions; negative symptoms; disorganization of thought, speech, and behavior) that last between 1 and 6 months. Patients with these symptoms may proceed on to a typical pattern of schizophrenia and should be diagnosed as such if the symptoms are present for more than 6 months. However, others may proceed to complete or near-complete resolution of their symptoms. These patients generally have good premorbid function, acute onset (often after a stressor), and complete resolution without residual deficits in psychosocial function. In addition, mood symptoms tend to be more prominent and a family history of mood disorder is common in these patients.
Psychological testing will reveal a pattern of symptoms more typical of schizophrenia (see Chapter 16). These findings will include the common symptoms of thought disorganization, hallucinations, and delusions. However, overt cognitive impairment (including memory problems) is uncommon, and prominent mood symptoms may occur. Persons with schizophreniform disorder may demonstrate frontal cortical regional deficits such as impaired performance on the Wisconsin Card Sorting Test.
Brain imaging studies may show the same results as those reported for schizophrenia. However, the differences often are less prominent, owing to the shorter duration of the condition. Alternatively, many patients do not show differences from normal controls, which may be associated with recovery. However, diagnostic imaging studies are not indicated.
A relative activation deficit in the inferior prefrontal region during performing the Wisconsin Card Sorting Test has been reported in both patients with schizophrenic and patients with schizophreniform disorder.
Schizophreniform disorder often follows a course typical of schizophrenia. If symptoms are present for more than 6 months, psychological and social deterioration typically associated with schizophrenia may occur. First generation antipsychotics such as haloperidol reduce the symptoms of the illness but will not prevent deterioration if the symptoms are present for more than 6 months. The potential beneficial effects of newer, atypical antipsychotics (e.g., clozapine, risperidone, olanzapine, quetiapine) in preventing psychosocial deterioration or cognitive impairment has been hypothesized but not conclusively established.
Although the major differential diagnoses are brief psychotic disorder and schizophrenia, the rapid onset of acute psychosis may be the most important diagnostic point. Attention should focus on the prior 6 months, the pattern of onset, and the presence of mood changes, alcohol and substance abuse, and other illness and prescriptive medications.
The treatment of schizophreniform disorder is similar to that of schizophrenia (see Chapter 16).
Hospitalization is usually required in the acute stages of overt psychotic symptoms.
Antipsychotic drugs represent the mainstay of symptomatic management, and resolution of psychosis often is fairly rapid. It has been shown that patients with schizophreniform disorder respond to antipsychotic treatment much more rapidly than do patients with schizophrenia. Sedative agents, especially benzodiazepines, may be needed to manage acute agitation. Electroconvulsive therapy may be indicated for some patients.
Psychotherapy is usually needed to help patients integrate the psychotic experience. Psychosocial support and rehabilitation is critical with these patients to help reduce the deterioration in function more typical of schizophrenia. Therefore, rapid treatment of symptoms and social reintegration of the patient is important.
After the resolution of acute symptoms, psychological, social, and occupational or educational treatment becomes the main focus of treatment. An acute schizophreniform psychotic episode represents a catastrophic event in the life of the patient, and psychotherapy is needed to help the patient understand the event and gain a sense of control over future episodes. A variety of issues should be discussed with the patient and his or her family or significant other: (1) the fundamental biological nature of the disorder; (2) the role of medication in controlling current and future symptoms, particularly the possible effect of symptom management on the evolution of the disorder; (3) the early-warning signs that indicate a return of psychosis; (4) the impact of the disturbance on the person’s life and that of the family; (5) the need for gradual reintegration into work or school; and (6) the importance of future psychosocial management, including intensive case management or occupational or educational rehabilitation.
Most individuals with schizophreniform disorder are simply in the early stages of the development of more typical schizophrenia. The 6-month cutoff for the diagnosis of schizophreniform disorder acknowledges that although patients with typical schizophrenia symptoms sometimes show complete resolution, this seldom occurs when the symptoms have been present for 6 months or more. Almost all patients will then proceed to a course more consistent with schizophrenia, with persistent deterioration and impairment in psychosocial functioning. Exceptions to this rule are very rare.
Schizoaffective Disorder
DSM-IV-TR Diagnostic Criteria
An uninterrupted period of illness during which, at some time, there is either a major depressive disorder, 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.
During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.
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.
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.
Specifytype:
Bipolar type: if the disturbance includes a manic or a mixed episode (or a manic or a mixed episode and major depressive episodes)
Depressive type: if the disturbance only includes major depressive episodes
(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000)
The lifetime prevalence of schizoaffective disorder is less than 1%. Schizoaffective disorder is characterized by prominent mood symptoms (mania or depression) occurring during the course of a chronic psychotic disorder. Phenomenologically, schizoaffective disorder holds the middle ground between mood disorders, especially psychotic mood disorders, and chronic psychotic conditions such as schizophrenia. The debate continues over whether schizoaffective disorder “belongs” to the spectrum of either schizophrenia or affective disorders, or represents a distinct category. Schizoaffective disorder likely represents a heterogeneous disorder with multiple distinct etiologies.
Recent research indicates that there appear to be distinct etiologies and outcomes depending on whether the course of schizoaffective disorder is typified by episodes of bipolar-type cycling or simple depressive episodes in the absence of mania.
In the bipolar variant, there is an increased proportion of family history of bipolar disorder (but not schizophrenia) and a better overall outcome. Although a family history of affective disorder is observed in the depressive variant, a history of psychotic disorder seems to be more common and outcome is poorer than in the bipolar form. Both variants usually have a better prognosis than does schizophrenia without prominent mood symptoms.
Patients with schizoaffective disorder exhibit symptoms consistent with DSM-IV-TR diagnostic Criterion A for schizophrenia. However, during the course of illness, there are superimposed episodes of depressive or manic symptoms. These patients would be diagnosed as having schizoaffective disorder, depressed or manic types, respectively. However, psychotic symptoms consistent with schizophrenia must be present for at least 2 weeks independently of the mania or depression syndromes.
Schizoaffective disorder, bipolar type, usually involves cycling of mania, depression, or mixed states in a way that is consistent with bipolar disorder. Similarly, patients with schizoaffective disorder, depressive type, may have repeated episodes of major depression, as in major depressive disorder. However, unlike depressive or bipolar disorders, there are consistent symptoms of schizophrenia in the absence of overt mood disorder. In schizoaffective disorder, depressive type, depressive episodes in which the patient meets full diagnostic criteria for major depression must be distinguished from the mood and negative symptoms associated with schizophrenia. For example, DSM-IV-TR criteria require the presence of persisting depressed mood for this diagnosis. Similarly, care should be taken to avoid misdiagnosing as mania agitation, hostility, insomnia, and other symptoms of an acute exacerbation of schizophrenia.
The results of psychological tests depend on the state of illness of a given patient. That is, although the typical results of schizophrenia usually are present (see Chapters 6, 16), characteristics of mood disorders also may be present. For example, psychological testing results will be consistent with depression or mania during corresponding episodes of illness. However, schizoaffective disorder, bipolar type, may be associated with less psychosocial and cognitive impairments than are schizophrenia or schizoaffective disorder, depressive type.
Generally, persons with schizoaffective disorder have a course of illness that is intermediate between the mood disorders (with a relatively better prognosis) and schizophrenia (with marked residual psychosocial deterioration). However, distinctions also can be made for patients within the schizoaffective spectrum. Patients with schizoaffective disorder, bipolar type (i.e., those with a history of manic or mixed bipolar episode), have a course of illness that is more similar to bipolar disorder. These patients often have better functioning between acute episodes of illness than patients with either schizophrenia or schizoaffective disorder, depressive type. Patients with schizoaffective disorder, depressive type, tend to exhibit more typical schizophrenic symptoms and course, although when the disorder is managed properly, the prognosis may be better than typical schizophrenia without comorbid depression.
Persons with schizophrenia are not immune to the occurrence of mood symptoms. When these features meet the diagnostic criteria for a mood disorder concurrently with features of schizophrenia, the diagnosis of schizoaffective disorder may be made. However, great care must be exercised in the evaluation in order to provide appropriate management of the disorder. For example, depressive symptoms not meeting full diagnostic criteria for a major depressive episode are common in schizophrenia and do not warrant a diagnosis of schizoaffective disorder per se. In fact, treatment of schizophrenia, especially management with atypical antipsychotics, may reduce these symptoms in many patients without reliance on antidepressants. Alternatively, the negative symptoms of schizophrenia (e.g., apathy, withdrawal, avolition, blunted affect) may be confused with the symptoms of depression. Again, these symptoms generally are treated more effectively with atypical antipsychotics. Finally, the agitation, insomnia, and grandiose delusions of an acutely psychotic patient with schizophrenia sometimes can be confused with mania. However, a careful examination of the course of illness, prodromal symptoms, and acute presentation can be helpful in making the correct diagnosis. For example, the acutely agitated patient who presents for treatment after a period of progressive withdrawal, isolation, and bizarre behavior is unlikely to have mania. A good diagnostic rule of thumb is to evaluate the patient for the presence of current or past mood disorder by excluding the symptoms of schizophrenia, prior to confirming the diagnosis of schizoaffective disorder.
Psychotic mood disorders also may present with a confusing picture. DSM-IV-TR diagnostic criteria are written to aid the clinician in making this distinction. The presence of mood symptoms concurrent with psychosis, even symptoms that otherwise appear to be more like typical schizophrenia (i.e., bizarre behavior or disorganized speech) are not adequate to make the diagnosis of schizoaffective disorder. This condition is understood as representing a mood disorder superimposed on a course of schizophrenia. Therefore, the criteria require the symptoms of schizophrenia to be present for at least 2 weeks in the absence of prominent mood symptoms meeting diagnostic criteria for major depression, mania, or mixed state. A course consistent with dysthymia concurrent with schizophrenia does not constitute a diagnosis of schizophrenia.
Once a definite diagnosis of schizoaffective disorder is made, treatment must take into consideration the necessity of managing both mood symptoms and psychotic symptoms (Table 17–1). Antipsychotics are required for the management of the psychotic features (see Chapter 17) and are typically used in these patients in acute manic states. Atypical antipsychotics are the first treatments of choice for several reasons. They can reduce both psychotic and more purely manic symptoms. They also exhibit mood stabilizing effects which are needed if cycling is present. Antidepressant drugs should be used as required in a manner similar to that discussed in Chapter 18 for the treatment of major depression. Alternatively, mood-stabilizing agents such as lithium, carbamazepine, or divalproex may be required adjunctively for the treatment of mood cycling. The effectiveness of lamotrigine as an adjunctive antidepressant or mood stabilizer in this population is largely unknown. Finally, psychosocial management often is needed in much the same fashion as with schizophrenia or schizophreniform disorder to aid in social reintegration.
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No single specific psychotherapeutic intervention has been recommended for schizoaffective disorder. However, patients may benefit from a combination of family therapy, social skills training, and cognitive rehabilitation.
Regardless of the diagnostic category (i.e., bipolar or depressive type), certain factors are associated with a poor outcome. They include insidious onset prior to the first psychotic episode; early onset of illness; poor or deteriorating premorbid functioning; the absence of a clear precipitating stressor; prominent negative symptoms in the prodromal, acute, or residual phases of illness; and a family history of schizophrenia. These factors are also associated with a poorer outcome in persons with schizophrenia without prominent mood symptoms.
Delusional Disorder
DSM-IV-TR Diagnostic Criteria
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.
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.
Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.
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.
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
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
(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000)
The cause of delusional disorder is unknown. A very small proportion of the population (roughly 0.03%) experience persistent, relatively fixed delusions in the absence of the characteristic features of other psychotic disorders like schizophrenia.
Etiologic theories about the development of delusional disorder abound, but systematic study is sparse. Early concepts of etiology focused on the denial and projection of unacceptable impulses. Hence, as examples, homosexual attraction would be reformulated unconsciously to homosexual delusions or a belief in a love relationship with a famous person. Other theories focus on projection of unacceptable sexual and aggressive drives, leading to paranoid fears of others. These and other psychodynamic theories have certain heuristic appeal, but little systematic study has been done to support these conjectures.
Little is known about the genetics of delusional disorder. Family studies have suggested a decided lack of increased family history of psychotic or mood disorder.
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