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

2. 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

3. 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)

4. 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

5. 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

6. 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

7. 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”

8. 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

9. 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

10. 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”

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. 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