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Schizophreniform Disorder

Schizophreniform disorder is characterized by the presence of the criterion A symptoms of

schizophrenia, including delusions, hallucinations, disorganized speech, disorganized or
catatonic behavior, and negative symptoms. The disorder, including its prodromal, active,
and residual phases, lasts longer than 1 month but less than 6 months.

Diagnostic features

In order to establish the diagnosis of schizophreniform disorder, the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), states that 2 (or more) of
the following signs must be present, each for a significant length of time during a 1-month
period (or less, if successfully treated).

• Delusions/hallucinations

• Disorganized speech (eg, frequent derailment, incoherence)

• Grossly disorganized or catatonic negative behavior symptoms, ie, affective

flattening, alogia, or avolition

Only one criterion A symptom is required if delusions are bizarre, if hallucinations consist
of a voice that is keeping up a running commentary on the person's behavior or thoughts,
or if 2 or more voices are conversing with each other.

Schizoaffective disorder and mood disorder with psychotic features must be excluded,
based on determining that (1) no major depressive, manic, or mixed episodes have
occurred concurrently with the active-phase symptoms or (2) if mood episodes have
occurred during active-phase symptoms, their total duration has been brief relative to the
duration of the active and residual periods.

The disturbance must not be the result of the direct physiological effects of a substance
(eg, drug of abuse, medication) or a general medical condition.

An episode of the disorder (including prodromal, active, and residual phases) must last at
least 1 month but less than 6 months. If the diagnosis must be made without waiting for
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recovery, it should be qualified as provisional.

Specify if the patient is without good prognostic features, defined as 2 or more of the
following:

• Onset of prominent psychotic symptoms within 4 weeks of the first noticeable

change in usual behavior or functioning

• Confusion or perplexity at the height of the psychotic episode

• Good premorbid social and occupational functioning

• Absence of blunted or flat affect

Distinguishing schizophreniform disorder from other medical and psychiatric conditions

that may present in a floridly psychotic state can be challenging. A detailed history should
focus on the following:

• Time of symptom onset

• Course

• Premorbid functioning

• Precipitants

• Physical health

• Use of medications

• Use of alcohol and other substances

• Family history

• Previous episodes (if any)

Such a detailed history may require the assistance of family members or others familiar
with the patient. The often abrupt onset of symptoms, in many cases coupled with the lack
of previous episodes, underscores the need for a toxicological and medical evaluation. A
full Mental Status Examination helps to establish the diagnosis.

Mental status is likely to manifest as a neutral or blunted mood and affect. Evidence of
paranoia, ideas of reference, delusions, and hallucinations are usually present. The
patient is usually fully oriented with intact memory. A strong possibility of homicidal and
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even suicidal ideation exists. Attempt to elicit command hallucinations because these
could drive a patient to hurt themselves and others. Disorientation and difficulties with
recall suggest an organic psychosis. Laboratory tests, including electrolytes, drug screen,
and thyroid studies also help in differential diagnosis.

Schizophrenia

The symptom profile of a schizophreniform disorder is identical to that of schizophrenia;

however, the total duration of illness, including prodromal or residual phases, must be less
than 6 months. Also, a deterioration in social or vocational functioning, required as part of
criterion B to make the diagnosis of schizophrenia, is not required for schizophreniform
disorder.

Brief psychotic disorder

A diagnosis of brief psychotic disorder requires that symptoms last 1 day to 1 month.
Schizophreniform disorder, as with schizophrenia, requires that symptoms be present for
at least 1 month.

Substance-induced psychotic disorder

Although substance-induced psychoses frequently resolve in less than 1 month, sustained

substance-induced psychoses in abstinent persons may be indistinguishable from
schizophreniform disorder. In the absence of objective diagnostic criteria, the distinction is
made based on the extent to which the clinician believes substances have contributed to
the current symptom profile.

Bipolar disorder and major depression with mood-incongruent features

In these disorders, the affective symptoms are clearly more prominent. In mood disorder,
the psychotic symptoms are secondary and less intense if present. Sometimes, in the
absence of an accurate history, diagnosis must be deferred until longitudinal observation
or a more accurate history is available.

Incidence, course, prognosis, and other features

As with schizophrenia, the prevalence of schizophreniform disorder is equally distributed

between the sexes, with peak onset between the ages of 18-24 years in men and ages
24-35 years in women. Unlike schizophrenia, in which prodromal symptoms may develop
over several years, schizophreniform disorder requires, among other features, a rather
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rapid period from the onset of prodromal symptoms to the point at which all criteria for
schizophrenia (except duration and deterioration) are met (within 6 mo).

According to the American Psychiatric Association, approximately two thirds of patients

diagnosed with schizophreniform disorder progress to a diagnosis of schizophrenia.
According to Benazzi et al, patients with a good prognosis tend to be retrospectively
associated with the affective spectrum of diagnoses rather than the schizophrenic.

Patients with schizophreniform disorder and patients with schizophrenia share many
anatomic and functional cortical deficits in neuropsychological, MRI, single-photon
emission computed tomography (SPECT), and positron emission tomography (PET)
studies. Studies have not yet elicited a consensus about whether ventricular enlargement
is predictive of poor outcome in patients with a schizophreniform disorder.

According to Troisi et al, in some patients with a schizophreniform disorder, the presence
of negative symptoms and poor eye contact appear to be prognostic of a poor outcome.
The patient is a 15-year-old girl. Two months ago, she started accusing her mother of
taking her things. Gradually, she started keeping to herself more and more. She began
smiling to herself and mumbling. She continued to attend school and, until recently, her
teacher did not notice the patient's problems. The patient subsequently became unable to
respond to the teacher's instructions because she was completely preoccupied by internal
stimuli. The school referred the patient to me.

She sat calmly and made little eye contact. When I looked at her, she looked away, smiled
blandly, and mumbled, "I am not going to tell you." When I gently pressed her, she told me
that she heard God talking to her and she also heard "God's enemy sometimes." She
refused to elaborate, saying it was a secret.

Her mood was neutral, and her affect was inappropriate at times. She was alert and fully
oriented. She could recall 3 of 3 items in 5 minutes; memory was intact. She was very
guarded, and no delusions were elicited. She denied any suicidal or homicidal ideation.
She did not exhibit any abnormal movements and tics. She was attentive and followed 3-
step commands. Her general fund of knowledge was average, and she appeared to have
average intellect. Her insight and judgment were poor. Her sleep had been reduced, and
her appetite was fair.

She did not have any physical problems and did not exhibit any signs or symptoms of
depression or of elations or euphoria. She did not take any drugs or alcohol and did not
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have evidence of trauma. Electrolytes, thyroid profile, and drug screen findings were
unremarkable.

In general, treatment aims to protect and stabilize the patient, to minimize the
psychosocial consequences, and to resolve the target symptoms with minimal adverse
effects. The patient who may be at risk of harming himself or herself or others requires
hospitalization. This allows for complete diagnostic evaluation and helps to ensure the
safety of the patient and others. A supportive environment with minimal stimulation is most
helpful.

As improvement progresses, help with coping skills, problem-solving techniques, and

psychoeducational approaches may be added for patients and their families. Patients may
benefit from a structured intermediate environment, such as a day hospital, during the
initial phases of returning to the community.

Psychotherapy

Virtually all psychotherapeutic treatment modalities employed in the treatment of patients

with schizophrenia may be helpful in treating patients with schizophreniform disorder.
Insight-oriented therapy is not indicated in patients with schizophreniform disorder
because they have limited ability to explore, and they may also be in denial.

Patients may experience a high degree of distress related to the onset of symptoms. Both
supportive and educational approaches may help patients to manage feelings of turmoil or
distress. Group psychotherapy may be helpful; however, patients with schizophreniform
disorder who are concerned about their prognosis may become frightened in groups in
which they are mixed with patients who have chronic schizophrenia. Thus, care must be
taken when forming therapy groups.

Family and social-vocational therapies

The treatment of patients with schizophreniform disorder frequently involves working with
family members and significant others. The family therapy strategies used in working with
the families of patients with schizophrenia are highly appropriate for patients with
schizophreniform disorder and their families.

In light of the variable course of schizophreniform disorder, brief treatment strategies with
clear goals may initially be helpful, although treatment strategies must be flexible to allow
for the transition to longer-term treatments for patients who progress to schizophrenia.
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Similarly, social-vocational function may be preserved in patients with schizophreniform

disorder. However, in patients exhibiting impairments in these areas, rehabilitative
strategies similar to those described for patients with schizophrenia are appropriate.

Pharmacotherapy

The pharmacotherapy for schizophreniform disorder is similar to that for schizophrenia.

At this time, atypical antipsychotics, such as risperidone, olanzapine, quetiapine, and

ziprasidone, are commonly used. In November 2003, a new atypical antipsychotic,
aripiprazole (Abilify) was approved by the US Food and Drug Administration. Aripiprazole
has a novel mechanism of action because it is a partial agonist at the dopamine receptors,
unlike its predecessors. Dosing strategies appear to be similar to recent approaches to
treating patients with schizophrenia, which emphasize the use of minimal but effective
doses.

Adequate treatment or prophylaxis of adverse extrapyramidal effects is critical to patient

tolerance of neuroleptic treatment and to medication therapy compliance. Neuroleptic-
resistant psychosis in patients with schizophreniform disorder may be managed through
approaches similar to those used in patients with schizophrenia, including adjustment of
the neuroleptic dose, addition of lithium, or addition of anticonvulsant agents and older
typical antipsychotics.

Antidepressants may be helpful for mood disturbances associated with schizophreniform

disorder, but care must be taken to monitor for possible exacerbations of psychotic
symptoms.

According to Stromgren, electroconvulsive therapy has been helpful in treating brief

reactive psychoses but is generally reserved for medication-resistant cases of
schizophreniform disorder.

Patient and family education

Efforts should be made to educate both the patients and their families about the early
signs of relapse and the need for continuing treatment. Those approaches advance the
overall aim of helping patients regain productive roles in society while reducing the risk of
relapse. Families with a high degree of emotional expression are likely to cause additional
stress to the patient and to increase the likelihood of relapse.
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Schizophreniform disorder is a serious mental disorder with symptoms similar to those of

schizophrenia. Early diagnosis of this disorder is crucial, as is early intervention with
medication, supportive therapy, and patient and family education.