CHAPTER 10: SCHIZOPHRENIA AND PSYCHOTIC DISORDERS

Substance-induced psychotic disorder

a variety of substances can produce hallucinations, delusions, verbal incoherence, and other psychotic behavior as a direct result of use or upon abrupt withdrawal.

Tactile hallucinations

concern being touched or having something just beneath the skin Example: The patient jumps up, whirls around, and looks confused. He explains that somebody just touched the back of his head, even though nobody else has been in the room with him for at least fifteen minutes.

Mood-congruent delusions

concern content that is entirely consistent with expressed mood.

Somatic hallucinations

concern false sensations experienced as coming from inside the body. Example: The patient complains that the eggs in his stomach are starting to hatch and are cutting his organs.

incoherence

concerns shifts with clauses , lack of clarity

Waxy inflexibility

decreased response to stimuli and a tendency to remain in an immobile posture Example: If you move a patient's arm in a certain position, they will hold that position.

Anhedonia

lack of enjoyment in all aspects of life

Hallucinations

sensory experiences for which there are no identifiable external stimuli

Schizophrenia and Psychotic Disorders

-The disorders considered in this chapter represent severe forms of psychopathology which are usually labeled psychoses. -The psychoses involve a loss of contact with reality. -The DSM-TR-IV includes several psychotic disorders.

Catatonic excitement:

wildly excited, violently or unpredictable movements. Example: The patient runs aimlessly through the lunchroom due to an episode of catatonic excitement, knocking over objects without apparent regard, and ignoring all outside attempts to stop or redirect her.

Schizophrenia- Disorganized Type

- Incoherent speech. -Hallucinations. -Fragments of delusional beliefs without organized theme. - inappropriate emotional responses frequently involving silly laughter and stereotypical mannerisms and grimaces -Earlier onset and more insidious course than other subtypes of the disorder. -The overall disorganization and impairment is severe in this type, and the course tends to be chronic without significant remissions.

Schizophrenia- Paranoid Type

- Prominent hallucinations or delusions that involve themes of persecution. -Later onset of symptoms. - Better clinical prognosis because of the coherence of the psychotic features. - May be at higher risk for suicidal or violent behavior

Clanging

- the use of a word because of how it sounds Example: "He went in entry in trying tieing sighing dying ding-dong dangles dashing dancing ding-a-ling!"

Loosening of Associations

-Loose, disjointed expression in speech. - Intruding associations may sometimes be highly personal and result in speech that in egocentric or autistic in extreme instances, almost totally unintelligible - "I'm a cut donator, donated by double sacrifice. I get two days for every one. That's known as double sacrifice; in other words, standard cut donator. You know, we considered it. He couldn't have anything for the cut, or for these patients."

late teens

Although most cases have onset between the ___________ to mid-thirties, Schizophrenia can be diagnosed at any age.

persistent

Although the delusions are __________ (at least one month in duration), they are focused on a theme apart from which there may be little impairment in behavior or functioning.

misdiagnosis

An difficulty involves reliably distinguishing Schizoaffective Disorder from Schizophrenia (in which there may be mood symptoms) and Mood Disorder with Psychotic Features (which may included hallucinations and delusions); __________ is not uncommon.

uncommon

Delusional Disorders appear to be ___________, with population incidence as low as 0.03%, and incidence in clinical settings at 2% or less.

Positive Symptoms

Delusions Hallucinations Disorganized thinking Agitation

rare

Diagnoses of Delusional Disorder are _______, in part, because such individuals do not seek help.

Psychosis:Disturbances in Sensation & Perception

False sensory experiences: The world may seem flat, unreal, or remote; objects seem unusually large or small; or time passes with unusual slowness or rapidity. Hallucinations: sensory experiences for which there are no identifiable external stimuli

Auditory hallucinations

Hearing voices. This is the most common. May narrate person's behavior or speak their thoughts, command person to do or not do something, argue, etc. Example: The patient hears a voice coming from the heating vent, even though he is the only one in the room. It threatens and insults the patient, and tells him to kill himself.

Avolition

Inability to initiate and persist in goal-directed activities (such as school or work)

Shared Psychotic Disorder

Key Symptoms: Delusions similar to another delusional person with whom person has close relationship Minimum Duration Required: none Sex Ratio: More common among females

Schizophrenia

Key Symptoms: Delusions, hallucinations, disordered speech & behavior Minimum Duration Requirement: 6 months Sex Ratio: More common among males

Brief Psychotic Disorder

Key Symptoms: Delusions, hallucinations, disorganized speech but duration less than one month Minimum Duration Required: 1 day Sex Ratio: Unclear

Schizoaffective disorder

Key Symptoms: Mood episode & hallucinations and delusions occurring together Minimum Duration Required: 2 weeks Sex Ratio: more common among females

Delusional Disorder

Key Symptoms: Non-bizarre delusions without other symptoms Minimum Duration Required: 1 month Sex Ratio: Equal

Schizophreniform Disorder

Key Symptoms: Same as Schizophrenia, but duration less than 6 months Minimum Requirements: 1 months Sex Ratio: Slightly more common among males

syntax

Loosening of Associations: The sentence structure or _______is not impaired; there is no evidence of educational or intellectual difficulties that might make communication ineffective. Instead the content is unusual and the meaning seems lost.

Psychotic symptoms

can appear transiently during periods of stress in individuals with many different Axis I and Axis II conditions and do not, in themselves, verify the presence of a psychotic disorder. - The symptom patterns and degree of impairment differ within the psychotic disorders as well.

Alternative Typologies:Premorbid adjustment levels

Low premorbid adjustment involves such characteristics as never married, never worked at one job for two years or more, no academic or vocational training after high school, no steady dating as a teenager, and never been deeply in love. Poor-premorbid patients are more deviant in their language and thought processes and possibly have a stronger genetic disposition to the disorder than do good-premorbid patients.

Psychotic Disorder Due to a Medical Condition

Many medical conditions can produce psychotic symptoms. For example: Neurological conditions, such as epilepsy and multiple sclerosis. Endocrine disorders, including hypothyroidism. Metabolic conditions. Fever. Any disorder with central nervous system involvement.

Visual hallucinations

can include lights, moving objects, places, and people Example: The patient stares fixedly at a blank wall, and his face shows a shifting emotional response as though he's watching a film. Later, he asks whether anyone else enjoyed the "projector show".

Catatonic immobility

cease bodily movements altogether Example: The patient sits immobile in a chair for sixteen hours, staring fixedly, apparently unaware of other people or his own bodily needs.

Reactive Schizophrenia

characterized by a relatively normal social and intellectual development followed by an abrupt form of an acute reaction, frequently in response to known life stressors. The person with such an acute reaction has a good chance of recovery.

Word salad

collection of words seem as if they were thrown together and tossed, like a salad, before presentation. Example: "It was shockingly not of the best quality I have known all such evildoers coming out of doors with the best of intentions!"

delusional thinking

Much of the ___________ and behavior is logical if one accepts a basic premise for example that a certain group is conducting a conspiracy.

Schizophrenia-Catatonic Type

Psychomotor disturbances involving: - Rigid immobility. - excessive motor activity - echolalia - Echopraxia. - Unresponsiveness to environmental stimuli, often for long periods of time.

Affective flattening

The person's range of emotional expression is clearly diminished; poor eye contract; reduced body language

Brief Psychotic Disorder

The psychotic indications involve at least one positive symptom (delusions, hallucinations, disorganized speech, or disorganized behavior), and are not explained by the effects of drugs or medical conditions that can cause brief psychosis. - Fully recover after experience

Schizophrenia: Outcomes

The rapid or acute onset of positive and florid symptoms, occurring later in life in someone with good premorbid adjustment, is associated with better prognosis for recovery than a gradual, insidious onset of negative symptoms, beginning earlier in life in someone with poor premorbid adjustment.

False sensory experiences

The world may seem flat, unreal, or remote; objects seem unusually large or small; or time passes with unusual slowness or rapidity.

Disturbances in Language and Thought

There are two main disturbances in language and thought: Loosening of Associations. Delusions

Diagnosis of Psychotic Disorders:DSM-IV-TR Criteria

There is no assumption that these disorders share a common cause, a common pathway, or even a common fundamental set of symptoms.

Schizophrenia- Residual Type

This category is applied to individuals who have previously experienced episodes of Schizophrenia, but who currently show none of the active, prominent psychotic features. Negative symptoms such as affective flattening or poverty of speech or attenuated forms of active symptoms are present.

Shared Psychotic Disorder

This disorder occurs when an individual develops a delusion in the context of a close personal relationship with another person who already has an established delusion. The delusion is similar in content to the already-established delusion held by the other person (sometimes called the "inducer"), who most often is dominant in the relationship. Most cases seem to involve an inducer who is schizophrenic, who shares the delusion with a person of close blood relation or connected by marriage, often in conditions or relative social isolation. It is rare, and may be more common in females.

psychosis and mood disorders

Those with Schizoaffective Disorder show a combination of symptoms of both _____________ and ________________________.

Schizophrenia-Catatonic Type

Waxy flexibility and extreme negativism may be present.

Persecutory delusions

delusions concern the theme of being plotted against, attacked, cheated, threatened, or persecuted in some way by other various people or groups. Example: "They are out to get me. They put a bug on my phone and they are watching my internet history." Example: "The Russians are trying to poison me with radioactive particles delivered through my tap water." Example: A man refuses to affix his signature to anything, even something so trivial as a birthday card, because he fears the government is watching him and will use the evidence to track him down.

Type II Schizophrenia

describes cases of the disorder in which negative symptoms predominate, such as flat affect, avolition, alogic and social withdrawal

Type I Schizophrenia

describes cases of the disorder in which positive symptoms predominate, such as prominent delusions and hallucinations. - outcomes more positive

Inappropriate emotions

emotional expression with no clear relationship to events in the social environment.

Flattened affect

emotional state in psychotic conditions characterized by a lack of ranges of emotions; emotions are shallow, flattened, or blunted.

Erotomanic delusions

false beliefs that another person, often someone famous or of higher status or authority, is in love with the individual

Bizarre delusions

false beliefs that could not possibly be true, given what is known about the world Example: The patient insists his neighbors are actually actors, and that all his doings are seen by millions of strangers on television. Example: That radiation is being transmitted into an apartment from a hostile foreign power, causing indigestion and diarrhea.

Delusions of reference

false beliefs that events, people, or things in the immediate environment have a special and unique significance for the individual. Example: The news anchor is directly communicating with the patient during the 6pm news.

Somatic delusions

false convictions that concern the body Example: A patient believes his internal organs have become infested with and partially consumed by large purple worms.

Grandiose delusions

grossly inflated self-importance, fame, power, wealth, or knowledge. Example: A patient believes that he is the smartest person in the world, probably the entire universe. Example: "I am Jesus Christ."

Alogia

impoverished speech Example: Q: Do you have any children? A: Yes. Q: How many? A: Two. Q: How old are they? A: Six and sixteen. Q: Are they boys or girls? A: One of each. Q: Who is the sixteen-year-old? A: The boy. Q: What is his name? A: Edmond. Q: And the girl's? A: Alice.

psychotic state

includes many symptoms, such as: Disturbances in Language and Thought. Disturbances in Sensation and Perception. Disturbances in Motor Behavior. Emotional Disturbance. Social Withdrawal.

Mood-incongruent delusions

involve content that is not consistent with the prevailing mood. Example: If one was depressed, in a negative mood state, the belief that one's body is rotting would be a mood-congruent delusion; the belief that one had unlimited wealth and power would be mood-incongruent.

Olfactory hallucinations

involve odors, usually unpleasant as well Example: The patient complains of an intensely foul odor, which nobody else in the room can detect. A few minutes later, the patient has a seizure.

Gustatory hallucinations

involve the perception of a taste, most often an unpleasant one. Example: The patient complains that his food tastes rotten, although the flavor seems normal to everyone else at the table.

Delusional Disorder

involves a more limited range of psychotic symptoms.

Schizophrenia

involves either a decline from a prior level or function or a failure to meet expected levels, and this change is usually apparent to others who know the person.

Schizophreniform Disorder

involves symptoms that are identical to those of Schizophrenia's Criterion A, including hallucinations, delusions, disorganized speech and behavior, and negative psychotic symptoms.

Brief Psychotic Disorder

involves the sudden onset of psychotic symptoms that last more than one day but do not persist more than a month, with eventual return to full functioning.

Schizophrenia- Undifferentiated

meets the criteria for Schizophrenia, but not the criteria for Paranoid, Disorganized, or Catatonic subtypes. This subtype, frequently diagnosed, illustrates that schizophrenic symptom patterns do not conform neatly to the previous three subcategories.

Neologisms

new words that the speaker invents, often by combining existing words. Example: "The only problem I have is my frustionating!"

Echopraxia

person imitates the movements of others.

Thought broadcasting delusions

the belief that others can hear or receive one's thoughts Example: A woman refuses to explain her problem, saying, "I know you know what I'm thinking. Everybody hears what I'm thinking."

Delusions of being controlled

the belief that some external force or agent is manipulating one's movements Example: A man cowers whenever a delivery truck passes his house. He believes the trucks contain machines which the government uses to control his behavior. Example: "The government put a chip in my neck to control me."

Thought insertion delusions

the belief that some external person or agency is inserting thoughts into one's consciousness. Example: The patient repeatedly complains of having disturbingly violent thoughts, which, she claims, are being sent to her by Satan.

Delusional jealousy

the incorrect conviction that a person's spouse or sexual partner has been or is being unfaithful. Example: The patient insists that the significant other is cheating regardless of any evidence to the contrary

Echolalia

the person repeats whatever someone else says Example: You greet a new patient by asking, "How are you feeling today?" He replies, "Today? Feeling today? How are YOU feeling today?"

loose associations

which involves shifts between clauses of topics or referential frames , Deficits in logical continuity of speech, with rapid shifts from one topic of conversation to another. A characteristic of schizophrenia also called derailment.

Two-thirds of

___________ those with Schizophreniform Disorder will likely develop either Schizophrenia or Schizoaffective Disorder.

Hyper-metaphorical speech

a form of overgeneralization. Example: My brain is a cave filled with wonders.

Process Schizophrenia

an early and gradual onset of symptoms and had a poor prognosis for recovery

Delusions

are extreme convictions that are firmly held in spite of what nearly everyone else in the subculture would consider incontrovertible evidence to the contrary -They are distinguished from ideas by their fixedness. -There are a number of subtypes of delusions; these categories of delusions are not mutually exclusive.

Alogia

A poverty of speech, such as brief, empty replies

Negative Symptoms

Affective flattening - The person's range of emotional expression is clearly diminished; poor eye contract; reduced body language Alogia - A poverty of speech, such as brief, empty replies Avolition - Inability to initiate and persist in goal-directed activities (such as school or work)

Young Adulthood

Age of onset is usually _________________________, and prognosis tends to be better than that for Schizophrenia but worse than that for Mood Disorders

predominant theme

Delusional Disorder: The diagnosis is subtyped according to the ___________ of the delusion: Erotomanic. Grandiose. Jealous. Persecutory. Somatic. Mixed. Unspecified.

Delusions

Delusional Disorder: non-bizarre, and do not include prominent auditory or visual hallucinations

Psychotic Disorders: Schizophrenia

Currently the diagnosis of Schizophrenia requires two psychotic symptoms during a one-month active phase - unless one of the "cardinal" or "indicator" symptoms is present: - Either bizarre delusions or auditory hallucinations that have the form of a running commentary or conversation

equal rates

Delusional Disorder seems occur at _________ in males and females, although males may be more likely to show the jealous subtype.

Psychosis:Disturbances in Motor Behavior

Psychotic persons may engage in strange, stereotyped gestures, postures, or facial grimaces.

males

Schizophrenia is slightly more common among _________.

6 months

Schizophrenia: As a condition of the diagnosis, signs of disorder must persist for at lease ________.

1%

Schizophrenia: Most estimates put the prevalence rate at about ___of the population.

Nicotine Dependence,

Schizophrenia: Rates for comorbid substance-related disorders, especially __________ are quite high

Psychosis:Social Withdrawal

Schizophrenic individuals tend to avoid close interpersonal relationships, spend much of their time alone, and retreat more and more into their own fantasy world. The withdrawal is both physical and psychological.

Other Psychotic Disorders:DSM-IV-TR Diagnoses

Schizophreniform Disorder Schizoaffective Disorder Brief Psychotic Disorder Delusional Disorder Shared Psychotic Disorder Additional Psychotic Disorders

Psychosis

Severe psychological disturbance involving personality disorganization and loss of contact with reality

Schizophrenia:Alternative Typologies

The DSM-IV-TR acknowledges that the subtypes are of only limited value in research or treatment response. Alternative typologies are being considered. One possibility is a three-factor dimensional model with psychotic, disorganized, and negative factors. Other typologies Process and reactive schizophrenia. Type I and Type II schizophrenia. Premorbid adjustment levels.

1 month

The diagnosis of Schizophreniform Disorder is given only if the duration of symptoms is at least ________ but less than six months.

Brief Psychotic Disorder

The disorder can be specified With Marked Stressors, Without Marked Stressors, or With Postpartum Onset (if the condition began within 4 weeks of giving birth). Due to their brevity, not many cases are seen in clinical settings, and their incidence is unknown.

Schizoaffective Disorder

The disorder is coded according to its mood symptoms, as either Bipolar Type or Depressive Type. Females are more likely than males to receive the diagnosis of ______________, largely because females tend to show more frequent mood disorder, and the Depressive subtype of Schizoaffective Disorder is most common.