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Schizophrenia
Definition
One of the greatest challenges to the student of schizophrenia is to learn
about and understand the multiplicity of signs and symptoms that arise from
its underlying cognitive and emotional impairments. The characteristic
symptoms include dysfunctions in nearly every capacity of which the human
brain is capable—perception, inferential thinking, language, memory, and
Schizophrenia and Other Psychotic Disorders 109
executive functions. The symptoms are sometimes divided into two groups:
positive and negative. Positive symptoms (e.g.> hearing voices) are
characterized by the presence of something that, should be absent.
Negative symptoms (e.g., avolition), on the other hand, are characterized
by the absence of something that should be present- One research-based
approach to classifying signs and symptoms recognizes three dimensions:
psychotic, disorganized, and negative.
In DSM-IV-TR, schizophrenia is defined by a group of characteristic
symptoms, such as hallucinations, delusions, or negative symptoms (i.e.,
affective flattening, alogia); deterioration in social, occupational, or
interpersonal relationships; and continuous signs of the disturbance for at
least 6 months. In addition, schizoaffective disorder and mood disorder with
psychotic features have been ruled out, and the disturbance is not due to the
direct physiological effects of a substance or a general medical condition. (See
Table 5-1 for the DSM-IV-TR diagnostic criteria for schizophrenia.)
Epidemiology
The worldwide prevalence of schizophrenia has been estimated at between
0.5% and 1%.; Schizophrenia can develop at any age, but the mean age at the
first psychotic episode is about 21 years for men and 27 for women. Of
persons with schizophrenia, 9 of 10 men—but only 2 of 3 women—develop
the illness by age 30 years. Age at onset is probably under both genetic and
environmental control, but it is unknown why women develop the illness
later than men. Patients with schizophrenia tend not to marry and are less
likely to have children than persons in the general population.
People with schizophrenia are at high risk for suicidal behavior. About one-
third will attempt suicide, and 1 in 10 will eventually kill themselves. Risk
factors for suicide include male gender, age less than 30 years,
unemployment, chronic course, prior depression, past treatment for
depression, history of substance abuse, and recent hospital discharge.
Clinical Findings
Because schizophrenia is characterized by so many different types of
symptoms, clinical investigators have tried to simplify the conceptualization
of the disorder. Using factor analysis, research has repeatedly identified
three dimensions (or groups of related symptoms) in schizophrenia:
Schizophrenia and Other Psychotic Disorders 111
psychoticism, disorganization, and negative symptoms. The many
symptoms of schizophrenia, and their frequency, are summarized in Table
5-2.
The Psychotic Dimension
The psychotic dimension refers to hallucinations and delusions two classic
"psychotic" symptoms that reflect a patient's confusion about the loss of
boundaries between him or herself and the external world. Hallucinations
are perceptions experienced without an external stimulus tothe sense organs
and have a quality similar to a true perception. Patients with schizophrenia
commonly report auditory, visual, tactile, gustatory, or olfactory
hallucinations or a combination of these hallucinations. Auditory
hallucinations are the most frequent; they are commonly experienced as
noises, music, or, more typically, speech ("voices"). The voices may be
mumbled or heard clearly, and they may speak words, phrases, or sentences.
Visual hallucinations may be simple or complex and include flashes of light,
persons, animals, or objects. Olfactory and gustatory hallucinations are often
experienced together, especially as unpleasant tastes or odors. Tactile
hallucinations may be experienced as sensations of being touched or pricked,
electrical sensations, or the sensation of insects crawling under the skin,
which is called formication.
Delusions involve disturbance in thought rather than perception; they are
firmly held beliefs that are untrue as well as contrary to a person's
educational and cultural background. Delusions occurring in schizophrenic
patients may have somatic, grandiose, religious, nihilistic, sexual, or
persecutory themes (Table 5-3). The type and frequency of the delusions
tend to differ according to one's culture. For example, in the United States, a
patient might worry about being spied on by the FBI or CIA; in sub-Saharan
Africa, a Bantu or Zulu patient would more likely worry about persecution
by demons or spirits.
Alogia Persecutory 81
Poverty of speech 53 Jealous 4
Poverty of content of speech 51 Guilt, sin 26
Blocking 23 Grandiose 39
Tangentiality 50
Incoherence 23
Illogicality 23
Circumstantiality 35
Pressure of speech 24
Distractible speech 23
Clanging 3
The following case is of a patient seen in our hospital and illustrates many
of the symptoms found in schizophrenia:
after graduating from college but continued to live with her mother.
She was first hospitalized at age 25 after developing the belief that her
neighbors were harassing her. Over the next 20 years, Jane developed the
belief that she was at the center of a government cabal to change her identity.
The FBI, the judicial system, the Roman Catholic Church, hospital personnel,
and, it seems, most of her neighbors were involved. She believed that her
neighbors were recruited to spy on her, harass her, and generally make her
life miserable. She would often overhear them plotting to assault or rape her.
At age 49, Jane was hospitalized after her landlord reported that she was
pounding on the ceiling and walls of her apartment with a broom and yelling
as she attempted to stop the perceived harassment by her neighbors.
At the time of her present hospitalization, Jane's landlord had complained
about her yelling and screaming. Jane reported that she was simply
responding to the discomfort her landlord and neighbors had caused by
"zapping" her with electronic beams in an effort to harass her.
She believed that electromagnetic waves were being used to control her
actions and thoughts and described a bizarre sensation of electricity moving
around her body when the landlord was nearby.
Jane cooperated well with her physicians and had no evidence of depressed
mood, but she was clearly upset about her hospitalization, which she
thought was unnecessary. Her speech was markedly circumstantial,
although she spoke in a clear, strong voice that one might expect after years
of teaching. She cooperated with her treatment plans. After 1 month of
antipsychotic therapy, Jane remained delusional but was less concerned
about her perceived harassment. Because of her poor insight and history of
medication noncompliance, Jane was given an intramuscular antipsychotic
before discharge.
Other Symptoms
Lack of insight is common in schizophrenia. A patient may not believe that he
or she is ill or abnormal in any way. Orientation and memory usually are
normal, unless they are impaired by the patient's psychotic symptoms,
inattention, or distractibility.
Nonlocalizing neurological soft signs occur in many patients and include
abnormalities in stereognosis, graphesthesia, balance, and proprioception.
Some patients have disturbances of sleep, sexual interest, and other bodily
functions. Many schizophrenic patients have inactive sex drives and derive
little or no pleasure from sexual activity.
Alcohol and drug abuse are especially common in patients with
schizophrenia. Drug-using patients tend to be young, male, and poorly
compliant with treatment; they also tend to have frequent hospitalizations.
It is believed that many abuse drugs in an attempt to treat their depression
or their medication side effects (e.g., akinesia) or to ameliorate their lack of
motivation and pleasure.
Schizophrenia and Other Psychotic Disorders 117
Subtypes of Schizophrenia
Five subtypes of schizophrenia are recognized in DSM-IV-TR: paranoid,
disorganized, catatonic, undifferentiated, and residual. Their usefulness is
primarily descriptive because their reliability and validity are not
established. As a practical matter, many patients seem to fit several of these
subtypes during the course of their illness.
Course of Illness
For many the illness begins with a prodromal phase, which typically occurs
in the mid to late teens and is characterized by subtle changes in emotional,
cognitive, and social functioning. This is then followed by an active phase,
118 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
during which psychotic symptoms develop. The person usually does not
disclose these symptoms to others right away, and many patients go for as
long as 2 years before symptoms become so troubling that a psychiatrist is
consulted. The psychotic symptoms usually respond relatively well to
antipsychotic treatment, but ongoing problems such as blunted emotions or
odd behavior tend to persist as the person passes into a residual phase.
During that phase acute exacerbations may occur from time to time, even
when the patient continues to take medication. Typical stages of
schizophrenia are outlined in Table 5-4.
Because schizophrenia is such a serious illness, it can be difficult to "break
the news" about the diagnosis to the patient and his or her family at the time
of the first outpatient evaluation or hospital admission. The first question
that they will ask is: what does the future hold? For many years two different
kinds of messages were taught to clinicians. The most common teaching has
been that schizophrenia is a severe chronic illness with a poor outcome.
Alternatively, clinicians were sometimes taught the "rule of thirds": about
one-third of patients first diagnosed with schizophrenia will have a
relatively good outcome, with minimal symptoms and mild impairments in
cognition and social functioning; one-third will have a poor outcome, with
persistence of psychotic symptoms, prominent negative symptoms, and
significant psychosocial impairment; and one-third will have an outcome
somewhere in the middle. As originally formulated, the rule of thirds was
based on relatively limited clinical observation rather than rigorous scientific
studies. Nonetheless, these limited studies stressed an important fact:
schizophrenia has a heterogeneous outcome. Several well-designed
longitudinal studies have been conducted during recent years that
incorporated cognitive measures and structural brain imaging obtained
from magnetic resonance imaging (MRI) scans. Although it is difficult to
definitively predict outcome for a specific patient based on these studies, a
variety of features haye been identified that are associated with good and
poor outcome. These are summarized in Table 5-5. Among these, IQ is the
strongest predictor of outcome, with age at onset, gender, severity and type
of initial symptoms, and structural brain abnormalities also having some
predictive value.
Additionally, cross-cultural studies have shown that patients in less
developed countries tend to have better outcomes than those in more
developed countries. It may be that the schizophrenic patient is better
accepted in less developed societies, has fewer external demands, and is
more likely to be taken care of by family members. Women, in general, tend
to have a better outcome than men in their response to medication and in
their long-term course.
Schizophrenia and Other Psychotic Disorders 119
Differential Diagnosis
Schizophrenia should be thought of as a diagnosis of exclusion because the
consequences of the diagnosis are severe and limit therapeutic options. First,
a thorough physical examination and history should be performed to help
rule out medical causes of schizophrenic symptoms. Psychotic symptoms
are found in many other illnesses, including substance abuse (e.g.,
hallucinogens, phencyclidine, amphetamines, cocaine, alcohol), intoxication
due to commonly prescribed medications (e.g., corticosteroids,
anticholinergics, levodopa), infections, metabolic and endocrine disorders,
tumors and mass lesions, and temporal lobe epilepsy of many years'
duration. Routine laboratory tests may be helpful in ruling out medical
etiologies. Testing may include a complete blood count, urinalysis, liver
enzymes, serum creatinine, blood urea nitrogen, thyroid function tests, and
serologic tests for evidence of an infection with syphilis or HIV. Computed
tomography or MR1 may be useful in selected patients to rule out brain
disorder (e.g., tumors, strokes) during the initial workup for new-onset
cases.
The major differential diagnosis involves separating schizophrenia from
schizoaffective disorder, mood disorder, delusional disorder, and
personality disorders (Table 5-6). The chief distinction from schizoaffective
disorder and psychotic mood disorders is that in schizophrenia, a full
depressive or manic syndrome either is absent, develops after the psychotic
symptoms, or is brief relative to the duration of psychotic symptoms. Unlike
delusional disorder, schizophrenia is characterized by bizarre delusions,
and hallucinations are common. Patients with personality disorders,
particularly those disorders within the eccentric cluster (e.g., schizoid,
schizotypal, and paranoid), may be characterized by indifference to social
relationships and have a restricted affect, bizarre ideation, or odd speech,
but they are not psychotic.
Other psychiatric disorders also must be ruled out, including
schizophreniform disorder, brief psychotic disorder, factitious disorder with
psychological symptoms, and malingering.
that they are not encoded in DNA and could potentially produce mutations
or influence gene expression, most are also biological rather than
psychological and include factors such as birth injuries, poor maternal
nutrition, or maternal substance abuse. Current studies of the neurobiology
of schizophrenia examine a multiplicity of factors, including genetics,
anatomy (primarily through structural neuroim-
Genetics
There is substantial evidence that schizophrenia has a strong genetic component.
Summaries of family studies have shown that siblings of schizophrenic patients have
about a 10% chance of developing schizophrenia, whereas children who have one
parent with schizophrenia have a 5%-6% chance. The risk of family members
developing schizophrenia increases markedly when two or more family members
have the illness. The risk of developing schizophrenia is 17% for persons with one
122 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
sibling and one parent with schizophrenia and 46% for the children of two
schizophrenic parents. Twin studies have been remarkably consistent in
demonstrating high concordance rates for identical twins—an average of 46%,
compared with 14% concordance in nonidentical twins.
Adoption studies show that the risk for schizophrenia is greater in the biological
relatives of index adoptees with schizophrenia than in the biological relatives of
mentally healthy control adoptees.
There have been numerous attempts to identify genes using both genome-
wide linkage surveys and methods based on genetic association (i.e., case-
control and family association-based methods). However, obtaining robust
results that can be replicated in independent data sets has generally been
difficult. For instance, positive mapping studies have been reported on
chromosomes 1, 6, 8,10,11,13, and 22, but often to very broad chromosomal
regions and with different groups often mapping to nonoverlapping regions
of the same chromosome arm. A possible exception to this pessimistic
outcome are a few vulnerability genes that have recently been identified for
schizophrenia. These genes include neuregulin 1, dysbindin, catechol-O-
methyltransferase (COMT), Disrupted-iri-Schizophrenia (DISC), and brain-
derived neurotrophic factor (BDNF). Most of these genes were identified
through follow-up on linkage and candidate gene studies using fine
mapping and guided by hypotheses about their role in neurodevelopment
or neurotransmission, and they now have had several replications. An
intriguing feature of these candidate susceptibility genes is that they may
explain selected features of the pathobiology of these diseases. For example,
COMT affects the production of dopamine, a neurotransmitter considered
to be functionally overactive in schizophrenia and that is blocked or down-
regulated by antipsychotic medications. Similarly, neuregulin has effects on
GABAergic and glutamatergic neurotransmission, which are also thought to
"be dysfunctional in schizophrenia.
Structural Neuroimaging and Neuropathology
Cerebral ventricular enlargement occurring in schizophrenia has now been
confirmed by numerous computed tomography studies. Sulcal enlargement
and cerebellar atrophy also are reported. Examination of ventricular size in
persons with and without schizophrenia over a broad age range suggests
that enlargement does not progress over time at a greater rate in
schizophrenic patients than normally and that structural brain abnormalities
are present from the outset. Ventricular enlargement is associated with poor
premorbid functioning, negative symptoms, poor response to treatment,
and cognitive impairment.
MRI also has been used to explore possible abnormalities in other specific
brain subregions, such as the thalamus, amygdala/hippocam- pus, temporal
Schizophrenia and Other Psychotic Disorders 123
lobes, and basal ganglia. Several studies have indicated that the size of
temporal regions was decreased in schizophrenia and that there may even
be a relatively specific abnormality in the superior temporal gyrus or
planum temporale that is correlated with the presence of hallucinations or
formal thought disorder.
Several studies have found decreased thalamus size in patients with
schizophrenia. Although the precise functions of the various thalamic nuclei
are still being mapped, the thalamus is a major relay station that could serve
functions such as gating or filtering or even generating input and output
because it receives afferent input from and sends efferent output to widely
distributed cortical and primary sensory and motor regions.
Sophisticated image analysis techniques have been developed to measure
the total volume of gray matter, white matter, and cerebrospinal fluid (CSF).
Most studies consistently show a decrease in total brain tissue volume in
schizophrenia and an increase in CSF in the ventricles and on the brain
surface. There appears to be a selective decrease in cortical gray matter,
although some investigators have found white matter decreases as well.
A variety of developmental anomalies are seen by MRI in some patients with
schizophrenia. The most consistently reported is an increased frequency of
large cavum septi pellucidi, a midline anomaly reflecting a fusion failure of
the septal leaflets. In addition, the frequency of partial callosal agenesis (a
severe mid line anomaly) appears to be modestly increased in schizophrenia.
Finally, findings that reflect abnormalities in neuronal migration (e.g., gray
matter heterotopias) are seen with increased incidence, although only in a
few patients.
Neurodevelgpmental Influences
Several lines of evidence have supported speculation that schizophrenia is a
neurodevelopmental disorder that results from brain injury occurring early
in life. For example, patients with schizophrenia are more likely than control
subjects to have a history of birth injury and perinatal complications that
could result in a subtle brain injury, thus setting the stage for the
development of schizophrenia. Minor physical anomalies (slight anatomical
defects of the head, hands, feet, and face) are relatively common in
schizophrenic patients and are themselves thought to reflect abnormal
neurodevelopment.
Increasingly, we are recognizing that neurodevelopment is an ongoing
process. A great deal of brain Iriatufation occurs during the teens and early
20s. The fact that schizophrenia often becomes manifest during this time
period suggests that it may be influenced by later neurodevelopmental
processes, perhaps under the influence of the significant hormonal changes
that occur during this time.
Clinical Management
The mainstay of treatment for schizophrenia is antipsychotic medication.
The probable mechanism of action of antipsychotics is their ability to block
postsynaptic dopamine D2 receptors in the limbic forebrain. This blockade is
thought to initiate a cascade of events responsible for both acute and chronic
therapeutic actions. These drugs also block serotonergic, noradrenergic,
cholinergic, and histaminic receptors to differing degrees, accounting for the
unique side effect profile of each agent.
Maintenance Therapy
Patients benefiting from short-term treatment with antipsychotic
medications are candidates for long-term maintenance treatment, which has
as its goal the sustained control of psychotic symptoms. At least 1-2 years of
treatment are recommended after the initial psychotic episode because of the
high risk of relapse and the possibility of social deterioration from further
relapses. At least 5 years of treatment for multiple episodes is recommended
because a high risk of relapse remains. Beyond this, data are incomplete, but
indefinite (perhaps lifelong) treatment is likely to be needed by most
patients.
Adjunctive Treatments
Adjunctive psychotropic medications are sometimes useful in the
schizophrenic patient, but their role has not been clearly defined. Many
patients benefit from anxiolytics (e.g., benzodiazepines) when anxiety is
prominent. Lithium carbonate, valproate, and carbamazepine have been
used to reduce impulsive and aggressive behaviors, hyperactivity, or mood
swings, although their effectiveness in patients with schizophrenia has not
been adequately determined. Antidepressants have been used to treat
depression in schizophrenic patients and appear to be effective.
Psychosocial Interventions
As hospitalizations have become briefer, the locus of treatment has shifted
to outpatient settings and to the community. Hospitalization now is
reserved for schizophrenic patients who pose a danger to themselves or
others; who refuse to properly care for themselves (e.g., refuse food or
fluids); or who require special medical observation, tests, or treatments. (See
Table 5-7 for the reasons to hospitalize schizophrenic patients.)
Patients with schizophrenia who do not need to be hospitalized may benefit
from partial hospital or day treatment programs, especially patients with
substantial symptoms that have not responded adequately to medication.
These programs generally operate on weekdays, and patients return home
in the evenings and on weekends. Psychopharmacological management is
provided along with psychosocial rehabilitation.
Schizophrenia ami Other Psychotic Disorders 127
Family Therapy
Family therapy, combined with antipsychotic medication, has been shown
to reduce relapse rates in schizophrenia. Families often want to learn more
about the nature of the illness. They need realistic and accurate information
about the cause of illness, prognostic indicators, and available treatments.
They also will benefit from learning how to improve communications with
their schizophrenic relative, while learning to minimize criticism and
emotional overinvolvement ("high expressed emotion"). This approach will
help to decrease the patient's level of stress and reduce risk of relapse.
Alcohol and Drug-Related Disorders 128
Cognitive Rehabilitation
Cognitive rehabilitation therapy has as its goal the remediation of abnormal thought
processes known to occur in schizophrenia and uses techniques pioneered in the
treatment of brain-injured persons. Work with schizophrenic patients is focused on
improving informationprocessing skills such as attention, memory, vigilance, and
conceptual abilities. Cognitive content approaches focus on changing the schizophrenic
patient's abnormal thoughts (e.g., delusions) or his or her responses to them and his or
her abnormal experiences (e.g., hallucinations). Patients learn various coping strategies
such as listening to music to mask auditory hallucinations or reality testing of delusional
beliefs.
Psychosocial Rehabilitation
The goal of psychosocial rehabilitation is to integrate the patient back into his or her
community rather t£ian segregating the patient in separate facilities, as has occurred in
the past. In many locations, patient clubhouses are available to promote psychosocial
rehabilitation, such as Fountain House, a program in New York that patients help to
manage. Appropriate and affordable housing is a major concern for many patients, and
depending on the community, options may range from supervised shelters and group
homes (halfway houses) to boarding homes to supervised apartment living. Group
homes provide peer support and companionship, along with on-site staff supervision.
Supervised apartments provide greater independence and offer the availability and
backup of trained staff.
Vocational interventions can help patients find and maintain paid jobs. Vocational
rehabilitation may involve supported employment, competitive work in integrated
settings, and more formal job training programs. A simple, repetitive job environment
offering both interpersonal distance and on-site supervision may be the best initial
setting, such as that found in a sheltered workshop. Although some patients will not be
employable in any setting because of apathy, amotivation, or chronic psychosis,
employment should be encouraged in able patients. A job will serve to improve self-esteem,
provide additional income, and provide a social outlet for the patient.
Key points to remember about schizophrenia
1. Psychotic symptoms should be treated aggressively with medication, j
• Second-generation antipsychotics are the first-line therapy because
they are effective and well tolerated.
• Intramuscular medication is useful in uncooperative or poorly
compliant patients.
Delusional Disorders
Delusional disorders are characterized by the presence of well-systematized, nonbizarre delusions
accompanied by affect appropriate to the delusion and occurring in the presence of a relatively
well-preserved personality. The delusions will have lasted at least 1 month; behavior is generally
not odd or bizarre apart from the delusion or its ramifications; active-phase symptoms that may
occur in schizophrenia (e.g., hallucinations, disorganized speech) are absent; and the disorder is
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130 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
not due to a mood disorder, is not substance induced, and is not due to a medical condition (see
Table 5-8).
The core feature of delusional disorder is the presence of a well-systematized, encapsulated,
nonbizarre delusion. Nonbizarre delusions are ones that, although technically possible, are
improbable nonetheless. (An example of an impossible delusion is the belief that one is controlled
by green Martians.) The term systematized indicates that the delusion and its ramifications fit into
a complex, all-encompassing scheme that makes logical sense to the patient. The term encapsulated
indicates that apart from the delusion or its ramifications, the patient generally behaves normally,
or at least is not obviously odd or bizarre.
Clinical Findings
Patients with delusional disorder tejad to be socially isolated, seclusive, and chronically
suspicious. Those with persecutory or jealous delusions sometimes become angry and
hostile, emotions that can lead to violent outbursts. Many patients become litigious and
end up as lawyers' clients rather than as psychiatrists' patients. Sexual dysfunction and
depressive symptoms are common. Patients are frequently overtalkative and
circumstantial, particularly when discussing their delusions.
The following DSM-IV-TR subtypes are based on the predominant delusional theme:
Persecutory type: The belief that one is being treated badly in some way
• Erotomanic type (de Clerambault's syndrome): The belief that a person, usually of
higher status, is in love with the patient
• Grandiose type: The belief that one is of inflated worth, power, knowledge, or identity
or that one has a special relationship to a deity or famous person
• Jealous type: The belief that one's sexual partner is unfaithful
• Somatic type: The belief that one has some physical defect, disorder, or disease, such
as AIDS
The residual category unspecified type is for patients who do not fit the previous
categories (e.g., those who have been ill less than 1 month), and the category mixed type
is for those with delusions characteristic of more than one subtype but without any
single theme predominating. The following patient illustrates the erotomanic subtype:
Doug, a 33-vear-old restaurant manager, was brought to the hospital under court order.
It was alleged that he had harassed and threatened a young woman. After admission, the
following story unfolded.
Doug had had a 4 1/2-year fantasy relationship with a comely young shop clerk who had
recently married. He had become convinced that the woman was in love with him,
although they had never met. He took as evidence of her affection glances and'smiles that
they had exchanged when they occasionally crossed paths in their small town. After
becoming convinced of her love, he mailed a "sexual business letter" to her after learning
her name and address. Doug continued to send love letters over the next few years and
kept careful track of her whereabouts. There were no other communications, but the
letters indicated his belief that she was infatuated with him and his desire that she act on
it. He once wrote: "What do you think 1 am? A can of vegetables that can just sit on your
shelf to open or throw awav whenever it suits you?"
The young woman became concerned and complained to the police, who warned Doug
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132 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
not to call or write to her. The warning had little effect. (Interestingly, Doug himself
complained to the police about his imagined harassment by her.) The woman and her
husband eventually sought a court order for Doug's hospitalization when the letters to
her developed a more threatening tone and >a "no contact" order failed to keep him away
from the shop where she worked. Doug felt jilted bv the woman's relationship and
subsequent marriage, and he had suggested in recent letters that the three get together to
"work things out."
Doug was indignant about his hospitalization. Although he was circumstantial in
describing his fantasy relationship, there was no evidence of a mood disorder,
hallucinations, or bizarre delusions. He reported a history of a similar relationship 10
years earlier, consisting mostly of letters, which ended only when the girl moved out of
town. Doug was a loner with few friends but functioned well in his position at work and
was active in several community organizations.
At his mental health hearing Doug denied that his behavior was inappropriate, but he
agreed to undergo outpatient psychiatric treatment.
The young woman eventually moved out of town.
Differential Diagnosis
The major differential diagnosis involves separating delusional disorder from mood
disorders with psychotic features, schizophrenia, and paranoid personality. The chief
distinction from psychotic mood disorders is that in delusional disorder, a depressive or
manic syndrome is absent, develops after the psychotic symptoms, or is brief in relation
to the psychotic symptoms. Unlike schizophrenia, delusional disorders are characterized
by nonbizarre delusions and generally either no hallucinations or hallucinations that are
not prominent or are very brief. (Tactile and olfactory hallucinations may be present
when they are related to the delusional theme.) Furthermore, patients with delusional
disorders do not develop other symptoms typically associated with schizophrenia, such
as incoherence or grossly disorganized behavior, and personality is generally preserved.
Persons with paranoid personality may be suspicious and hypervigilant, but they are
not delusional.
Clinical Management
Because delusional disorder is so uncommon, treatment recommendations are based on
clinical observation and not careful research. Anecdotal evidence suggests that response
to antipsychotics is poor and that although they may help relieve agitation and anxiety
they may leave the core delusion intact. Any of the antipsychotics can be used, although
one of the second-generation antipsychotics may be preferred because of their more
favorable side effect profile (e.g., risperidone, 2-6 mg/day; olanzapine, 5-20 mg/day).
Monohypochondriacal paranoia (i.e., delusional disorder, somatic subtype) l>as been
specifically reported to respond to the antipsychotic pimozide at dosages of 4-8 mg/day.
Selective serotonin reuptake inhibitors (e.g., fluoxetine, paroxetine) also have been
reported to be helpful in reducing delusional beliefs in some patients.
The physician should make an effort to develop a trusting relationship with the patient,
after which he or she may gently challenge the patient's beliefs by showing how they
interfere with the patient's life. The patient should be assured of the confidential nature
of the doctor- patient relationship. Tact and skill are necessary to persuade a patient to
accept treatment, and the physician must neither condemn nor collude in the beliefs.
Group therapy is not recommended because patients with delusional disorder tend to
be suspicious and hypervigilant and are prone to misinterpret situations that may arise
in the course of the therapy.
Schizoaffective Disorder
The term schizoaffective was first used in 1933 by Jacob Kasanin to describe a small group
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of patients who had a mixture of psychotic and mood symptoms and who were severely
ill. In DSM-IV-TR, its hallmark is the presence of either a depressive or a manic episode
concurrent with symptoms characteristic of schizophrenia, such as bizarre delusions (see
Table 5-9). During the illness, hallucinations or delusions must be present for 2 weeks or
more in the absence of prominent mood symptoms, but mood symptoms must be
present for a substantial portion of the total duration of the illness. (Some experts
consider a "substantial portion" to constitute 30% or more of the total duration.) Finally,
the effects of medical illness and drugs must have been excluded as having caused the
symptoms.-There are two subtypes: the bipolar type, marked by a current or previous
manic syndrome, and the depressive type, marked by the absence of any manic
syndromes.
Relatively little is known about the epidemiology of schizoaffective disorder, but it is
thought to have a prevalence of less than 1% and to occur more often in women. The
diagnosis is common in psychiatric hospitals and clinics but is primarily a diagnosis of
exclusion. The differential diagnosis for schizoaffective disorder consists primarily of
schizophrenia, psychotic mood disorders, and disorders induced by medical illness or
drugs. In schizophrenia, the duration of all episodes of a mood syndrome is brief relative
to the total duration of the psychotic disturbance. Although psychotic symptoms may
occur in persons with mood disorders, they are generally not present in the absence of
depression or mania, helping to set the boundary between schizoaffective disorder and
psychotic mania or depression. It is usually clear from the history, physical examination,
or laboratory tests when a drug or medical illness has initiated and maintained the
disorder.
Family studies have shown an increased prevalence of both schizophrenia and mood
disorders in relatives of patients with schizophrenia. In general, schizoaffective patients
have higher rates of schizophrenia and lower rates of mood disorders in their families
than do patients with mood disorder but higher rates of mood disorder and lower rates
of schizophrenia in their families than do patients with schizophrenia. Other research
also suggests that patients with schizoaffective disorder are a mixture of patients with
schizophrenia with severe mood symptoms and mood disorder patients with severe
psychoses.
The signs and symptoms of schizoaffective disorder include those seen in schizophrenia
and the mood disorders. The symptoms may present together or in an alternating
fashion, and psychotic symptoms may be mood congruent or mood incongruent. The
course of schizoaffective disorder is variable but represents a middle ground between
that of schizophrenia and the mood disorders. Some studies indicate that the bipolar
type of schizoaffective disorder has an outcome similar to that of bipolar disorder and
that the depressed type of schizoaffective disorder has a prognosis similar to that of
schizophrenia. A worse outcome is associated with poor premorbid adjustment,
insidious onset, lack of a precipitating stressor, predominance of psychotic symptoms,
early onset, unremitting course, and a family history of schizophrenia.
The treatment of schizoaffective disorder should target both psychotic and mood
symptoms. With second-generation antipsychotics, a single drug may adequately target
both psychotic and mood symptoms, so these drugs may represent an ideal first-line
treatment. Some patients may benefit from the addition of a mood stabilizer (e.g.,
lithium, carbamazepine, valproate) or an antidepressant. Patients not responding to
medication may respond to electroconvulsive therapy, although medication is typically
reinstituted for long-term maintenance. Schizoaffective patients who are a danger to
themselves or others or who are unable to properly care for themselves should be
hospitalized.
Schizophreniform Disorder
Gabriel Langfeldt used the term schizophreniform in 1939 to describe acute, reactive
psychoses that occurred in persons with normal personalities. In DSM-IV-TR, the
definition at schizophreniform disorder requires that these features be present: 1) the patient
has psychotic symptoms characteristic of schizophrenia, 2) the symptoms are not due to
a substance or general medical condition, 3) schizoaffective disorder and mood disorder
with psychotic features have been ruled out, and 4) the duration is at least 1 month but
less than 6 months.
The diagnosis changes to schizophrenia once the symptoms have extended past 6
months, even if the only symptoms remaining are residual ones, such as blunted affect.
The diagnosis is considered provisional in patients who have not recovered, because
many persons who meet criteria for schizophreniform disorder will eventually meet
criteria for schizophrenia.
Research has not supported the validity of schizophreniform disorder as a distinct
diagnosis. The diagnosis appears to identify a widely varying group of patients, most of
whom eventually develop either schizophrenia, a mood disorder, or schizoaffective
disorder. Clearly, the proper boundaries of this disorder remain in question. Its main use
is to guard against premature diagnosis of schizophrenia. Treatment of
schizophreniform disorder has not been systematically evaluated. The principles for its
management are similar to those for an acute exacerbation of schizophrenia, which is
described earlier in this chapter.
Patients with a brief psychotic disorder have psychotic symptoms that last at least 1 day
but no more than 1 month, with gradual recovery. Psychotic mood disorders,
schizophrenia, and the effects of drugs or medical illness have been ruled out as causing
the symptoms. Signs and symptoms are similar to those seen in schizophrenia, including
hallucinations, delusions, and grossly disorganized behavior. The three subtypes are 1)
with marked stressor(s), 2) without marked stressor(s), and 3) with postpartum onset. In
the past, patients with marked stressors would have received a diagnosis of a reactive,
hysterical, or psychogenic psychosis. This disorder is similar to what Scandinavian
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The essence of shared psychotic disorder is the transmission of delusional beliefs from
one person to another. In DSM-IV-TR, a shared psychotic disorder involves the presence
of a delusion that develops in the context of a close relationship with another person,
who already has an established delusion. In the past, these rare cases were called folie a
deux, a French term meaning "double insanity."
Most cases of shared psychotic disorder involve two members of the same family, most
commonly siblings, a parent and child, or a husband and wife. Its development requires
the presence of a dominant person with an established delusion and a more submissive
and suggestible person who gains the acceptance of the more dominant individual by
adopting his or her delusional beliefs. Clinical observation suggests that separation may
result in rapid improvement of the submissive person.
Self-Assessment Questions
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