Section XIV: Addressing the Complexities – Schizophrenia Spectrum and Other Psychotic Disorders

Statistic: Approximately 1% of the population has a thought disorder (NAMI, 2003).

Schizophrenia spectrum and other psychotic disorders are defined by an abnormality in one or more of the following five areas:

• Delusions;
• Hallucinations;
• Disorganized thinking or speech;
• Grossly disorganized or abnormal motor behavior (which includes catatonia);
• Negative symptoms (diminished emotional expression and avolition).

Positive symptoms are often referred to as behavioral or perceptual excesses or a distortion of normal functions. Examples that were given earlier are considered positive symptoms: delusions, hallucinations, disorganized speech, and disorganized or catatonic behaviors.

Negative symptoms include behavioral deficiencies such as poor hygiene, poor eye contact, social withdrawal, flattened affect (decreased emotional expressiveness), poverty of speech (little verbal communication), poverty of thought (inability to form thoughts in a usual time frame), and lack of initiation of goal directed behaviors, called “avolition.”

Two or more of the above are required for a significant portion of time during a 30-day period (or less if successfully treated), and one must be delusions, hallucinations or disorganized thinking or speech. Avolition is defined in the glossary of technical terms in the DSM 5 (pp. 815-831) as “an inability to initiate or persist in goal-directed activities.  When severe enough to be considered pathological, avolition is pervasive and presents the person from completing many different types of activities (e.g., work, intellectual pursuits, self-care)”.

 

Key Knowledge Point to Follow:

Catatonic schizophrenia no longer exists as a separate subtype of schizophrenia. This does not mean that catatonia is not manifest in a certain percentage of clients who present with signs and symptoms of schizophrenia. Most people, when they think of catatonia, envision a client who presents with physical immobility: they don’t move. In fact, catatonia can present with catatonic excitement - fast sporadic movements – as well as stupor, rigidity and stiffness.   

This dual presentation of catatonia means that it is often under recognized. However, this is likely not the most important complexity when it comes to this symptom traditionally associated with schizophrenia. There is currently occurring a substantial debate among researchers about whether catatonia might constitute an “independent diagnostic entity.” (Bartolommei, et al.) However, resolution of this debate and any change in how catatonia connects with diagnosis and the DSM-5 will have to await further research and the next edition – at least – of the DSM. 

Please make note of the Clinician-Rated Dimensions of Psychosis Symptom of Severity two-page chart in the DSM 5 on pages 743-744.  It is an excellent resource for accurate, detailed diagnosis of psychosis.

The schizophrenia spectrum and other psychotic disorders delineated in the

DSM 5 are as follows:

 

Delusional Disorder                                                                     F22

Brief Psychotic Disorder                                                             F23

Schizophreniform Disorder                                                       F20.81

Schizophrenia                                                                                F20.9

Schizoaffective Disorder, bipolar type                                  F25.0

Schizoaffective Disorder, depressive type                           F25.1

 

Substance/Medication Induced Psychotic Disorder*

  *See page 111 in DSM 5 for specific codes by

    Substance or medication

 

Psychotic Disorder Due to Another Medical Condition

      With delusion                                                                          F06.2

      Without delusions                                                                 F06.0

Catatonia Associated with another Mental disorder

     (Catatonia Specifier)                                                                F06.1

Catatonia Disorder Due to Another Medical Condition   F06.1

Other Specified Schizophrenia Spectrum and Other

     Psychotic Disorder                                                                  F28

Unspecified Schizophrenia Spectrum and Other

     Psychotic Disorder                                                                  F29

 

Delusional Disorder occurs when a person exhibits delusions (not hallucinations unless they are directly related to the delusions).  Manic or major depressive episodes may have happened, but they must be very brief compared to the length of the delusional periods.  Delusions must occur for one month or more; and this

diagnosis cannot not be related to the physiological effects of any substance use or medical condition.   A person’s ability to function is not impaired and her/his behavior is not described as bizarre or odd.  There are seven subtypes of this disorder.

Brief Psychotic Disorder results when a client exhibits hallucination, delusions, disorganized speech or greatly disorganized behavior for at least one day and no more than one month.  Due not confuse culturally accepted behavior as a psychotic episode.  After the resolution of the brief psychosis, the client returns to full functioning.  As always, be sure to rule out any substance use or medical condition that may present with the above listed behaviors.  Be sure to specify if marked or unmarked stressors (such as a brief psychosis) are present and if the onset occurred post-partum or with catatonia.

Schizophreniform Disorder is diagnosed when two or more if the following appear for a major part of one month but less than six months: 1) delusions; 2) hallucinations; 3) disorganized speech; 4) grossly disorganized or catatonic behavior; and 5) the negative symptoms of schizophrenia which are diminished emotional expression or avolition.   Before this diagnosis may be used, be sure to rule out schizoaffective disorder and depressive or bipolar disorder.  Specifiers include a) with good prognostic features; b) without good prognostic features; and 3) catatonia.  Schizophrenia and schizophreniform are very similar with the major difference being length of time of the symptom picture.  Schizophreniform can only last one to six months and the individual recovers fully.  “Provisional” may be used if the length of time is unclear at the time of the evaluation.

Schizophrenia is a leading cause of disability with over 3.5 million persons diagnosed in the US.  Three-quarters of persons with schizophrenia develop the illness between 16 and 25 years of age. The disorder is at least partially genetic.

(Schizophrenia and Related Disorders Alliance of America, SRDAA, 2008-2017). 

Any diagnosis must delineate if it is a first episode, a multiple episode, continuous or unspecified. In addition, it must be noted if the episode is acute, in partial remission or full remission. Catatonia is another specifier. As in Schizophreniform disorder (listed above), two or more if the following appear: 1) delusions; 2) hallucinations; 3) disorganized speech; 4) grossly disorganized or catatonic behavior; and 5) diminished emotional expression or avolition.

However, the time frame is six months or more with serious impairment to daily emotional, thinking or behavioral functioning.  The course and outcome of this diagnosis are not clear and the psychosis often becomes less with age.  Many persons live with Schizophrenia throughout their lives.  Mental health professionals will serve persons living with severe and persistent mental illness by reframing the language to not label the person as a disease.

 

Key Knowledge Point to Follow: 

Differential Diagnosis: Schizophrenia may sometimes be misdiagnosed, as some symptoms are similar to the effects of amphetamines and cocaine. One must distinguish these symptoms, such as delusions and hallucinations, from use of these drugs by taking careful assessment of the patient. It can also be challenging to differentiate Schizophrenia from Schizoaffective Disorder, and Mood Disorder with Psychotic Features, as each of these has a mood component to its diagnosis.

 

Key Knowledge Point to Follow: 

Schizoaffective Disorder is very similar to schizophrenia, and it adds a mood disorder component to the disorder. Schizoaffective disorder has positive and negative symptoms - along with a bipolar mood component that differentiates its diagnosis. A person with schizoaffective disorder experiences depression and hypomania or mania, while at the same time maintaining the positive and negative symptoms of a thought disorder.

Making a diagnosis between schizoaffective disorder and bipolar disorder may take some experience and guidance, but the main distinguishing features are which of these disorders has the most presence, the psychosis or the mood disturbance. If the positive or negative symptoms only occur in the presence of the mood disturbance, the diagnosis of bipolar with psychotic features is most appropriate.

Key Knowledge Point to Follow:

 Differential Diagnosis: Schizophrenia and related disorders may be difficult at times to distinguish from one or more personality disorders.  Some of these difficulties in differential diagnosis will be addressed when the complexities of personality disorders are examined.

 

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