PSY600: Diagnosis and treatment of mental health disorders Class 9: Schizophrenia Spectrum and other Psychotic Disorders

Key Sx of Psychosis Hallucinations Delusions Sensory experience without external stimulation of relevant sensory organ Auditory by far most common with Schizophrenia Delusions False beliefs that are firmly held despite incontrovertible evidence to the contrary and despite what everyone else believes

Key Sx of Psychosis Disorganized Thinking/Speech Formal thought disorder inferred from speech Incoherence, loose associations, tangentiality Grossly Disorganized or Abnormal Motor Behavior Childlike silliness; unpredictable agitation; odd or unusual appearance/dress/ grooming; general difficulty with or disorganization of daily living activities Catatonic Bx (motor abnormalities)* Stupor; rigidity; mutism Negativism - resistance to being moved or following instructions Posturing (assuming and holding a body position) Excitement (purposeless or unstimulated excessive motor activity) * Catatonia can be diagnosed with several mental disorders (see DSM, p. 119)

Negative Sx of Psychosis Negative Sx – Diminution/loss of normal functions Diminished emotional expression (blunted/flat affect) Unresponsive facial expression Poor eye contact Reduced body language Avolition Inability to initiate or persist in goal-directed activities Sitting for extended periods; little interest in activities Alogia (poverty of speech) Brief, empty verbal responses Gives impression of diminution of thought Anhedonia – decreased ability to experience pleasure Asociality – lack of interest in social interactions

Criteria for Schizophrenia Criterion A - Two or more of the following for a one-month period (less if successfully treated). At least one Sx must be 1, 2, or 3. Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic Bx Negative Sx For a significant portion of the time since onset, level of functioning is markedly below level achieved prior to onset

Criteria for Schizophrenia Continuous signs of disturbance must persist for at least 6 months Active Sx: Criterion A Sx Prodromal (before 1st active phase) or Residual (between active phases) Sx Milder and less disabling versions of Criterion A Sx (other than negative Sx) Negative Sx – can be severe Rule out: Schizoaffective Disorder, mood disorders with psychotic features, substances, other medical conditions

Course of Schizophrenia Schizophrenia usually occurs in phases: Prodromal Phase Active Phase (Criterion A met) Residual Phase Specify course if at least one year has elapsed since initial onset First or multiple episodes combined with current degree of Sx presentation Continuous Specify if “With catatonia”

Schizophrenia .3-1% lifetime risk (DSM-5, 2013; Seligman, 2012) Not everyone has the same risk Usually begins in late adolescence or early adulthood Generally later onset for women Greater severity in men, particularly negative Sx Higher incidence in males High suicide risk: DSM and Seligman together show completed suicide rate of appx 5-13%, with 20-50% attempting

Culture and Schizophrenia Cultural awareness is particularly important with Schizophrenia, especially if clinician and patient do not share same background Beliefs/ideas that appear delusional in one culture may not be in another Language differences must be accounted for when assessing disorganized speech and alogia Normal affective expression varies by culture

Schizophreniform Disorder Criteria A, D, & E of Schizophrenia are met Functional impairment not required Episode has lasted from 1-6 months Specify: with or without good prognostic features Specify if: With catatonia Can be diagnosed with certainty only after Sx have remitted If Sx are ongoing, designate as “provisional”

Brief Psychotic Disorder Presence of one or more Criterion A Sx, other than negative Sx One Sx must be delusions, hallucinations, or disorganized speech Episode lasts from 1 day to 1 month, and there is a full return to premorbid level of functioning Can be diagnosed only after remission of Sx Specify if: With Marked Stressors – Sx occur after events that most would consider markedly stressful Without Marked Stressors – Sx do not occur after events that most would consider stressful With Postpartum Onset – if onset is during pregnancy or within 4 weeks postpartum Specify if: With catatonia

Schizoaffective Disorder Basic criteria Major depressive or manic episode concurrent with Sx that meet Criterion A for Schizophrenia At least 2 weeks of delusions or hallucinations in the absence of a major mood episode Sx of full major mood episode are present for the majority of the total duration of the active and residual phases of the illness Specify Bipolar or Depressive type Specify if: With catatonia Specify course after 1 year of duration of disorder

Delusional Disorder One or more delusion lasting at least 1 month Schizophrenia Criterion A has never been met Functioning largely intact and Bx not obviously odd or bizarre Specify Type: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified Specify if: With bizarre content Specify course after 1 year of duration of disorder

Differential Diagnosis Schizophrenia v. Schizoaffective Disorder W/ Schizoaffective, full mood episode Sx are concurrent with active phase most of the time; this is not usually true with Schizophrenia Schizophrenia v. Delusional Disorder There are no other Criterion A Sx present with Delusional Disorder Functioning is generally intact and Bx is not odd with Delusional Disorder Can be difficult to distinguish from some presentations of Schizophrenia

Differential Diagnosis Schizophrenia v. Schizophreniform Disorder W/ Schizophreniform, Sx present more than 1 month, but less than 6 months Decline in functioning not required Psychotic Disorder v. Mood Disorder with Psychotic Features It’s the latter if psychotic Sx occur ONLY in the presence of mood disturbance

Differential Diagnosis Schizophrenia v. PDDs PDDs have much earlier onset PDDs don’t have prominent delusions or hallucinations PDDs have more pronounced speech, social and affective deficits, and repetitive Bx Schizophrenia v. Cluster A Personality Disorders Paranoid, Schizoid, and Schizotypal P/Ds are considered to be on the Schizophrenia spectrum and can, in low number of cases, represent a prodromal phase of Schizophrenia With Personality Disorders, Criterion A will not be met

Treatment of Schizophrenia Goal usually to improve quality of life and functioning. Complete remission is unusual. Minimize Sx Prevent suicide Prevent relapse of active Sx Enhance self-esteem Improve social and occupational functioning Support patients, families, and caregivers

Treatment of Schizophrenia Treatment is usually thought of in three phases: Acute care Transitional care Chronic care (Maxmen, Ward, & Kilgus (2009)) Combination of medications and psychosocial interventions usually required Suicide rate is high for this Dx, and potential for violence, though not high, exists Periodically assess for danger to self and others

Treatment of Schizophrenia Acute care – stabilization and safety during active phases Hospitalization, usually during active phase Stabilization of active phase Sx Brief, frequent, reassuring therapeutic contact Typically brief stays with more reliance on transition placement Neuroleptic medications Traditional or atypical (fewer side-effects with atypicals) Most effective on positive Sx Create Tx team collaboration with family

Treatment of Schizophrenia Transitional care Plans for medication compliance and regular outpatient contact with mental health clinician Medication compliance often very difficult Family education, esp. re: suicide risk Begin psychosocial interventions once stable on meds Relapse prevention and plan Reduce stressors in environment Day treatment and halfway houses can be important in this stage Meds compliance

Treatment of Schizophrenia Psychosocial interventions Bx Tx – inpatient or outpatient to increase desirable Bx Skills training – social functioning, occupational functioning, self-management, meds management CBT – focus on thinking about stressful aspects of life and challenging beliefs, reality testing, coping/crisis management, normalizing/reducing stigma Social support is key, so family counseling/education is vital Teach family to reduce Emotional Expression (EE) This support increases compliance and reduces relapse rates Integrated Dual-Dx treatment if needed

Treatment of Schizophrenia Chronic care Long-term medication management Consider risk of tardive dyskinesia Socialization/productivity opportunities Promote self-worth and full recovery Relapse prevention Reduce stress Increase self-esteem and self-efficacy Acceptance and sense of purpose Address co-occurring disorders and suicidality Some schizophrenia patients can go on to productive, satisfying lives.

Prognosis for Schizophrenia Full and permanent remission of Sx unusual Relapse rates very high, even with Tx Px worse with Gradual, long-term onset Dual-Dx High EE family experiences Px better with Early, continual intervention and Tx compliance Acute onset Later in life onset Higher intelligence Good premorbid social and occupational functioning Stable partner relationship Positive family environment No family Hx of Schizophrenia