Psychotic Disorders
Psychosis describes a degree of severity, not a specific disorder. A psychotic patient has a grossly impaired sense of reality, often coupled with emotional and cognitive disabilities, which severely compromise the ability to function. The patient is likely to talk and act in a bizarre fashion, have hallucinations, or have strongly held ideas that are contrary to fact (delusions). He or she may be confused and disoriented and typically is not aware of the impairment (lacks insight).
This chapter covers the major psychotic disorders [i.e., conditions that present with some combination of psychotic symptoms at some time during their course (although the patients may be nonpsychotic most of the time)]. Recognize that these are descriptive groupings of clinical syndromes, not discrete diseases.
Schizophrenia
Disorganized type
Catatonic type
Paranoid type
Undifferentiated type
Residual type
Schizophreniform disorder
Brief psychotic disorder
Schizoaffective disorder
Shared psychotic disorder
Delusional (paranoid) disorder
Psychotic disorder due to a general medical condition
Substance-induced psychotic disorder
Psychotic disorder not otherwise specified (NOS)
DIFFERENTIAL DIAGNOSIS
Most psychotic disorders have an organic base, although poorly understood. Start by identifying any underlying medical and neurologic causes or psychoses due to substance intoxication or
withdrawal. Obtain a complete history and physical on all psychotic patients. Most psychotic disorders present with emotion and thinking disturbances in a patient with a clear sensorium, whereas obviously organic psychoses usually have a degree of delirium (e.g., clouding of consciousness, confusion, disorientation). Unfortunately, exceptions to either pattern are frequent. Possible organic causes of psychosis include almost any type of serious medical illness or drug abuse (see Chapters 5, 6, 14 and 15). Suspect an organic etiology if
withdrawal. Obtain a complete history and physical on all psychotic patients. Most psychotic disorders present with emotion and thinking disturbances in a patient with a clear sensorium, whereas obviously organic psychoses usually have a degree of delirium (e.g., clouding of consciousness, confusion, disorientation). Unfortunately, exceptions to either pattern are frequent. Possible organic causes of psychosis include almost any type of serious medical illness or drug abuse (see Chapters 5, 6, 14 and 15). Suspect an organic etiology if
The patient has significant memory loss, confusion, disorientation, or clouding of consciousness;
No personal or family history of serious psychiatric illness is known;
The patient has a serious medical illness or a chronic medical condition with periodic relapses;
The psychosis has developed rapidly (e.g., days) in a patient who previously had been functioning well.
Psychiatric conditions that may (but do not necessarily) reach psychotic proportions (addressed in other chapters) include the following:
Major depressive disorder or bipolar disorder (see Chapter 4): Look for the psychosis to coexist with and be dominated by an affective component (either manic or depressed) that preceded the development of the psychosis.
Brief psychotic disorders may occur from stress in patients with personality disorders of the histrionic, borderline, paranoid, and schizotypal types. In some obsessive-compulsive persons, a psychosis may at times develop if they fail to control their environment.
Some acute panic or rage attacks may be of psychotic intensity [e.g., rage in the patient with an explosive disorder (see Chapter 7)].
A few psychotic conditions develop in childhood and continue into the adult years [e.g., AUTISTIC DISORDER (DSM, p. 70, 299.00) and PERVASIVE DEVELOPMENTAL DISORDER NOS (DSM, p. 84, 299.80)].
Psychotic states occasionally may be mimicked unconsciously or even “faked”: Factitious Disorder with Predominantly Psychological Signs and Symptoms; Malingering.
SCHIZOPHRENIA
Schizophrenia is the most common psychotic disorder; almost 1% of people worldwide develop it during their lifetime; more than 2 million persons are affected in the United States. It occurs more frequently in urban populations and in lower socioeconomic groups, probably because of a “downward drift” (i.e., poorly functional unemployable persons end up in marginal settings). Poor environments do not “cause” the disorder, although they make it more intractable.
The diagnosis of schizophrenia has had a checkered history. Many different ways have been used to make the diagnosis, which have thus represented different populations of patients. The current diagnostic scheme (DSM-IV) uses specific objective criteria to define several forms of schizophrenia. Because no pathognomonic findings exist, “schizophrenia” is a clinical diagnosis that may represent a nonspecific syndrome of heterogeneous etiologies. However, biologic, genetic, and phenomenologic information suggest that it is a valid disorder(s). The five identified subtypes also are based on clinical variables.
Clinical Presentation
Although the nature of schizophrenia is uncertain, the current clinical description and method of making the diagnosis are more clear (DSM-IV).
Most schizophrenics are psychotic for only a small part of their lives. Typically they spend many years in a residual phase, during which time they display minor features of their illness. During these residual periods, patients may be withdrawn, isolated, and “peculiar.” They usually are noticeable to others and may lose their jobs or friends, both because of their own lack of interest and ability to perform and because they behave oddly. Their thinking and speech are vague and are believed by others to be odd and to “not quite make sense.” They may be convinced that they are different from others, believe that they have special powers and sensitivities, and have “mystical” or “psychic” experiences. Their personal appearance and manners deteriorate, and they may display affect that is blunted, flat, or inappropriate. Although they may maintain close to normal intelligence, they display significant cognitive deficits in memory, attention, frontal lobe function, etc., most of which can be demonstrated on neuropsychological testing. They are frequently anhedonic (unable to experience pleasure). Often this deterioration merely represents a gradual
worsening of a condition the patient has displayed for many years—the first psychotic episode may have been preceded by a similar period of eccentric thinking and behavior (prodromal phase).
worsening of a condition the patient has displayed for many years—the first psychotic episode may have been preceded by a similar period of eccentric thinking and behavior (prodromal phase).
A prepsychotic personality is seen in some chronic schizophrenics and is characterized by social withdrawal, social awkwardness, and marked shyness in a youth who has difficulty in school despite a normal IQ. An equally common pattern is involvement in minor antisocial activities in the year or two before the initial psychotic episode. Many of these patients have previously received the diagnosis of schizoid, borderline, antisocial, or schizotypal personality disorder. It is only when the first psychotic episode develops [normally in their teens or early 20s (men) or 20s and early 30s (women); a first “breakdown” after age 40 is unusual] that the diagnosis is changed to schizophrenia. Often a presumed precipitating stress can be identified. The typical acute psychosis displays a variable mixture of several of the following symptoms.
▪ Disturbance of Thought Form
These patients usually have a formal thought disorder (i.e., their thinking is frequently incomprehensible to others and appears illogical). Characteristics include
Loosening of associations (derailment or tangential associations): Patients’ ideas are disconnected. They may jump obliviously from topic to unconnected topic, confusing the listener. When this occurs frequently (e.g., in mid-sentence), the speech is often incoherent.
Overinclusiveness: Patients continually may disrupt the flow of their thoughts by including irrelevant information.
Neologisms: Patients coin new words (which may have a symbolic meaning for them).
Blocking: Speech is halted (often in mid-sentence) and then picked up a moment (or minutes) later, usually at another place. This may represent the patients’ ideas being interrupted by intrusive thoughts (e.g., hallucinations). These patients are often very distractible and have a short attention span.
Clanging: Patients choose their next words and themes based on the sound of the words they have just used rather than the thought content (e.g., “Yesterday I went to the store.” The patient looks around and then says, “I guess I’d better clean the floor.”).
Echolalia: Patients repeat words or phrases just spoken by another person, but without an apparent effort to communicate.
Concreteness: Patients of normal or above-average IQ think in abstract terms poorly.
Alogia: Patients may speak very little (but without being intentionally resistant; poverty of speech) or may speak a normal amount but say very little (poverty of speech content).
▪ Disturbance of Thought Content
Delusions are fixed false beliefs far beyond credibility that may be “bizarre” (e.g., “my right eye is a computer that controls the world”) or “nonbizarre” (just very unlikely; “the FBI follows me”) and remain unmodified despite clear evidence to the contrary. They are common in most serious mental disorders, but some specific forms of delusional thought are particularly frequent in schizophrenia. The more acute the psychosis, the more likely the delusion is to be disorganized and nonsystematized:
Bizarre confused delusions;
Persecutory delusions, particularly nonsystematic types;
Grandiose delusions;
Delusions of influence: Patients believe they can control events through telepathy;
Delusions of reference: Patients are convinced of “meanings” behind events and people’s actions that are directed specifically toward themselves;
Delusions of thought broadcasting: The belief that others can hear the patients’ thoughts;
Delusions of thought insertion: The belief that someone else’s thoughts have been inserted into the patients’ minds.
Many schizophrenic patients display lack of insight (1), that is, the patient is unaware of his or her own illness or of his or her need for treatment, even though the disorder is evident to others.
▪ Disturbance of Perception
Most common are hallucinations, usually auditory but also visual, olfactory, and tactile. Auditory hallucinations (most often voices— one or several) may include a running commentary about the patient and events, derogatory or threatening comments made to the patient, or direct orders to the patient (command hallucinations). The voices often (but not necessarily) are perceived as coming from outside the patient’s head, and occasionally the patient may hear his or her own thoughts spoken aloud (often to his or her shame or embarrassment). The voices are quite real to the patient, except in the early phases of the psychosis.
These patients may also have illusions, depersonalizations (feels as if they are observing themselves from the outside), derealizations (the world seems unreal), and a hallucinatory sense of bodily change.
▪ Disturbance of Emotions
Acutely psychotic patients may display various emotions and may switch from one to another in a surprisingly short time. Three frequent (but not pathognomonic) underlying affects are
Blunted or flat affect: The patient expresses very little emotion, even when it is appropriate to do so. He may appear to be without warmth.
Inappropriate affect: The affect may be intense, but it is inconsistent with the patient’s thoughts or speech.
Labile affect: Marked changes in affect over a short time.
▪ Disturbance of Behavior
Many different bizarre and inappropriate behaviors may be seen, including strange grimacing and posturing, ritual behavior, excessive silliness, aggressiveness, and some sexual inappropriateness. An acute psychotic attack can last weeks or months (occasionally years). Many patients have recurrences of the active phase periodically throughout their lives, typically separated by months or years. During the intervening periods, patients usually have residual symptoms (often with the degree of impairment gradually increasing over the years); however, a few patients are symptom free between acute episodes. Many schizophrenic patients in remission display early signs of a developing relapse—always look for them. These early signs include increasing restlessness and nervousness, loss of appetite, mild depression and anhedonia, insomnia, and trouble concentrating.
Classification
To be considered schizophrenic, a patient must (DSM, p. 312)
have had at least 6 months of
sufficiently deteriorated occupational, interpersonal, and selfsupportive functioning;
have been actively psychotic in a characteristic fashion for at least 1 month of that period; and
must not be able to account for the symptoms by the presence of a schizoaffective or major mood disorder, autism, or an organic condition.
The course of the illness should be classed as continuous, episodic with or without interepisode residual symptoms, or single episode in partial or full remission. Moreover, all schizophrenic patients should be classed as one of five recognized subtypes that describes the most frequently occurring behavioral manifestations
of the illness. Numerous subclassifications of schizophrenia have been used in the past, all unsatisfactory, and the current divisions share some of those deficiencies. Although genetic data suggest that schizophrenia is a fairly stable diagnosis (2), no comparable information exists for the subtypes. Symptomatically, they tend to overlap, and the diagnosis can shift from one to another with time (either during one episode or in a subsequent episode). Finally, over the years, the clinical presentations of many patients tend to converge toward a common picture of interpersonal withdrawal, flattened affect, idiosyncratic thinking, and impaired social and personal functioning. (At the same time, the course becomes more stable, with fewer acute symptoms or episodes.)
of the illness. Numerous subclassifications of schizophrenia have been used in the past, all unsatisfactory, and the current divisions share some of those deficiencies. Although genetic data suggest that schizophrenia is a fairly stable diagnosis (2), no comparable information exists for the subtypes. Symptomatically, they tend to overlap, and the diagnosis can shift from one to another with time (either during one episode or in a subsequent episode). Finally, over the years, the clinical presentations of many patients tend to converge toward a common picture of interpersonal withdrawal, flattened affect, idiosyncratic thinking, and impaired social and personal functioning. (At the same time, the course becomes more stable, with fewer acute symptoms or episodes.)
▪ Disorganized Type (DSM, p. 314, 295.10)
The patient has (a) blunted, silly, or inappropriate affect; (b) frequent incoherence; and (c) no systematized delusions. Grimacing and bizarre mannerisms are common. This is the most severe subtype of schizophrenia.
▪ Catatonic Type (DSM, p. 315, 295.20)
The patient may have any one (or a combination) of several forms of catatonia:
Catatonic stupor or mutism: Patient does not appreciably respond to the environment or to the people in it. Despite appearances, these patients are often thoroughly aware of what is going on around them.
Catatonic negativism: Patient resists all directions or physical attempts to move him or her.
Catatonic rigidity: Patient is physically rigid.
Catatonic posturing: Patient assumes bizarre or unusual postures.
Catatonic excitement: Patient is extremely (e.g., wildly) active and excited. May be life-threatening (e.g., because of exhaustion).
▪ Paranoid Type (DSM, p. 313, 295.30)
This is the most stable, least severe, and most common (3) subtype over time and usually develops later than other forms of schizophrenia. The patient must display consistent, often paranoid, delusions that he or she may or may not act on. These patients are often uncooperative and difficult to deal with and may be aggressive, angry, or fearful, but they are less likely to display disorganized incoherent behavior.
▪ Undifferentiated Type (DSM, p. 316, 295.90)
The patient has prominent hallucinations, delusions, and other evidence of active psychosis (e.g., confusion, incoherence) but without the more specific features of the preceding three categories.
▪ Residual Type (DSM, p. 316, 295.60)
The patient is in remission from active psychosis but displays symptoms of the residual phase (e.g., social withdrawal, flat or inappropriate affect, eccentric behavior, loosening of associations, and illogical thinking).
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