Schizophrenia Spectrum and

Other Psychotic Disorder

_____________________________

Submitted by:
Rhea Andrea F. Uy
BS Psychology 3-1

Submitted to:
Prof. Serafina Maxino
Professor in Abnormal Psychology

SCHIZOPHRENIA

Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and
behaves. People with schizophrenia may seem like they have lost touch with reality. Although
schizophrenia is not as common as other mental disorders, the symptoms can be very disabling.

DSM V Background and Criteria

Schizophrenia is a brain disorder that probably comprises multiple etiologies. The
hallmark symptom of schizophrenia is psychosis, such as experiencing auditory
hallucinations (voices) and delusions (fixed false beliefs). Impaired cognition or a
disturbance in information processing is an underappreciated symptom that interferes
with day-to-day life. People with schizophrenia have lower rates of employment,
marriage, and independent living compared with other people.
Schizophrenia is a clinical diagnosis. It must be differentiated from other psychiatric
and medical illnesses, as well as from disorders such as heavy metal toxicity, adverse
effects of drugs, and vitamin deficiencies. (See DDx and Workup.)
Treatment of schizophrenia requires an integration of medical, psychological, and
psychosocial inputs. The bulk of care occurs in an outpatient setting and is best
carried out by a multidisciplinary team. Psychosocial rehabilitation is an essential part
of treatment.
Antipsychotic medications, also known as neuroleptic medications or major
tranquilizers, diminish the positive symptoms of schizophrenia and prevent relapses.
Unfortunately, they are also associated with a number of adverse effects. (See
Treatment and Medication.)

Diagnostic criteria (DSM-5)

The specific DSM-5 criteria for schizophrenia are as follows :

The presence of 2 (or more) of the following, each present for a significant portion of time during a
1-month period (or less if successfully treated), with at least 1 of them being (1), (2), or (3): (1)
delusions, (2) hallucinations, (3) disorganized speech, (4) grossly disorganized or catatonic behavior,
and (5) negative symptoms

For a significant portion of the time since the onset of the disturbance, level of functioning in 1 or
more major areas (eg, work, interpersonal relations, or self-care) is markedly below the level
achieved before onset; when the onset is in childhood or adolescence, the expected level of
interpersonal, academic or occupational functioning is not achieved

Continuous signs of the disturbance persist for a period of at least 6 months, which must include at
least 1 month of symptoms (or less if successfully treated); prodromal symptoms often precede the
active phase, and residual symptoms may follow it, characterized by mild or subthreshold forms of
hallucinations or delusions

Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled
out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently
with the active-phase symptoms or (2) any mood episodes that have occurred during active-phase
symptoms have been present for a minority of the total duration of the active and residual periods
of the illness

The disturbance is not attributable to the physiologic effects of a substance (eg, a drug of abuse or a
medication) or another medical condition.
If there is a history of autism spectrum disorder or a communication disorder of childhood onset,
the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in
addition to the other required symptoms or schizophrenia are also present for at least 1 month (or
less if successfully treated)

In addition to the 5 symptom domain areas identified in the first diagnostic criterion,
assessment of cognition, depression, and mania symptom domains is vital for
distinguishing between schizophrenia and other psychotic disorders.
Various course specifiers are used, though only if the disorder has been present for at
least 1 year and if they do not contradict diagnostic course criteria. These specifiers
include the following :
First episode, currently in acute episode
First episode, currently in partial remission
First episode, currently in full remission
Multiple episodes, currently in acute episode
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous
Unspecified

The presence or absence of catatonia is specified. Individuals meeting the criteria for
catatonia receive an additional diagnosis of catatonia associated with schizophrenia to
indicate the presence of the comorbidity.
Finally, the current severity of the disorder is specified by evaluating the primary
symptoms of psychosis and rating their severity on a 5-point scale ranging from 0 (not
present) to 4 (present and severe).
 Schizophrenia subtypes were removed from DSM-5 because they did not appear to
help with providing better-targeted treatment or predicting treatment response.
Signs and Symptoms

Symptoms of schizophrenia usually start between ages 16 and 30. In rare cases,
children have schizophrenia too.

The symptoms of schizophrenia fall into three categories: positive, negative, and
cognitive.

Positive symptoms: “Positive” symptoms are psychotic behaviors not generally seen
in healthy people. People with positive symptoms may “lose touch” with some
aspects of reality. Symptoms include:
 Hallucinations
 Delusions
 Thought disorders (unusual or dysfunctional ways of thinking)
 Movement disorders (agitated body movements)

Negative symptoms: “Negative” symptoms are associated with disruptions to normal

emotions and behaviors. Symptoms include:
 “Flat affect” (reduced expression of emotions via facial expression or voice tone)
 Reduced feelings of pleasure in everyday life
 Difficulty beginning and sustaining activities
 Reduced speaking

Cognitive symptoms: For some patients, the cognitive symptoms of schizophrenia

are subtle, but for others, they are more severe and patients may notice changes in
their memory or other aspects of thinking. Symptoms include:
 Poor “executive functioning” (the ability to understand information and use it to make decisions)
 Trouble focusing or paying attention
 Problems with “working memory” (the ability to use information immediately after learning it)

Risk Factors
There are several factors that contribute to the risk of developing schizophrenia.

Genes and environment: Scientists have long known that schizophrenia sometimes

runs in families. However, there are many people who have schizophrenia who don’t
have a family member with the disorder and conversely, many people with one or
more family members with the disorder who do not develop it themselves.

Scientists believe that many different genes may increase the risk of schizophrenia,
but that no single gene causes the disorder by itself. It is not yet possible to use
genetic information to predict who will develop schizophrenia.

Scientists also think that interactions between genes and aspects of the individual’s
environment are necessary for schizophrenia to develop. Environmental factors may
involve:
 Exposure to viruses
 Malnutrition before birth
 Problems during birth
 Psychosocial factors

Different brain chemistry and structure: Scientists think that an imbalance in the

complex, interrelated chemical reactions of the brain involving the neurotransmitters
(substances that brain cells use to communicate with each other) dopamine and
glutamate, and possibly others, plays a role in schizophrenia.

Some experts also think problems during brain development before birth may lead to
faulty connections. The brain also undergoes major changes during puberty, and these
changes could trigger psychotic symptoms in people who are vulnerable due to
genetics or brain differences.

Treatments and Therapies

Because the causes of schizophrenia are still unknown, treatments focus on
eliminating the symptoms of the disease. Treatments include:

Antipsychotics
Antipsychotic medications are usually taken daily in pill or liquid form. Some
antipsychotics are injections that are given once or twice a month. Some people have
side effects when they start taking medications, but most side effects go away after a
few days. Doctors and patients can work together to find the best medication or
medication combination, and the right dose. Check the U.S. Food and Drug
Administration (FDA) website: (http://www.fda.gov/ ), for the latest information on
warnings, patient medication guides, or newly approved medications.

Psychosocial Treatments
These treatments are helpful after patients and their doctor find a medication that
works. Learning and using coping skills to address the everyday challenges of
schizophrenia helps people to pursue their life goals, such as attending school or
work. Individuals who participate in regular psychosocial treatment are less likely to
have relapses or be hospitalized. For more information on psychosocial treatments,
see thePsychotherapies webpage on the NIMH website.

Coordinated specialty care (CSC)

This treatment model integrates medication, psychosocial therapies, case
management, family involvement, and supported education and employment services,
all aimed at reducing symptoms and improving quality of life. The NIMH Recovery
After an Initial Schizophrenia Episode (RAISE) research project seeks to
fundamentally change the trajectory and prognosis of schizophrenia through
coordinated specialty care treatment in the earliest stages of the disorder. RAISE is
designed to reduce the likelihood of long-term disability that people with
schizophrenia often experience and help them lead productive, independent lives.
DELUSIONAL DISORDER
Delusional disorder is characterized by the presence of either bizarre or non-
bizarre delusions which have persisted for at least one month. Non-bizarre delusions
typically are beliefs of something occurring  in a person’s life which is not out of the
realm of possibility. For example, the person may believe their significant other is
cheating on them, that someone close to them is about to die, a friend is really a
government agent, etc. All of these situations could be true or possible, but the person
suffering from this disorder knows them not to be (e.g., through fact-checking, third-
person confirmation, etc.). Delusions are deemed bizarre if they are clearly
implausible, not understandable, and not derived from ordinary life experiences (e.g.,
an individual’s belief that a stranger has removed his or her internal organs and
replaced them with someone else’s organs without leaving any wounds or
scars). Delusions that express a loss of control over mind or body are generally
considered to be bizarre and reflect a lower degree of insight and a stronger
conviction to hold such belief compared to when they are non-bizarre. Accordingly, if
an individual has bizarre delusions, a clinician will specify “with bizarre content”
when documenting the delusional disorder.

People who have this disorder generally don’t experience a marked impairment in
their daily functioning in a social, occupational or other important setting. Outward
behavior is not noticeably bizarre or objectively characterized as out-of-the-ordinary.

The delusions can not be better accounted for by another disorder, such as
schizophrenia, which is also characterized by delusions (which are bizarre).  The
delusions also cannot be better accounted for by a mood disorder, if the mood
disturbances have been relatively brief. The lifetime prevalence of delusional disorder
has been estimated at around 0.2% .

Specific Diagnostic Criteria

1. Delusions lasting for at least 1 month’s duration.

2. Criterion A for Schizophrenia has never  been met. Note: Tactile and olfactory hallucinations
may be present  in Delusional Disorder if they are related to the delusional theme.Criterion A
of Schizophrenia requires two (or more) of the following,  each present for a significant
portion of time during a 1-month period  (or less if successfully treated):

A. delusions
B. hallucinations
C. disorganized speech (e.g., frequent derailment or incoherence)
D. grossly disorganized or catatonic behavior
E. negative symptoms, i.e., affective flattening, alogia, or avolition
 Note: Criteria A of Schizophrenia requires only one symptom if delusions are
bizarre or hallucinations consist of a voice keeping up a running commentary
on the person’s behavior or thoughts, or two or more voices conversing with
each other.

3. Apart from the impact of the delusion(s) or its ramifications,  functioning is not markedly
impaired and behavior is not obviously odd  or bizarre.

4. If mood episodes have occurred concurrently with delusions, their total duration has been
brief relative to the duration of the delusional periods.

5. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.

Specify type (the following types are assigned based on the

predominant delusional theme):
 Erotomanic Type:  delusions that another person, usually of higher status, is in love with the
individual

 Grandiose Type:  delusions of inflated worth, power, knowledge, identity, or special

relationship to a deity or famous person

 Jealous Type: delusions that the individual’s sexual partner is unfaithful

 Persecutory Type:  delusions that the person (or someone to whom the person is close)
is being malevolently treated in some way

 Somatic Type: delusions that the person has some physical defect or general medical
condition

 Mixed Type: delusions characteristic of more than one of the above types but no one theme
predominates

 Unspecified Type

Psychotherapy
Psychotherapy is usually the most effective help in person suffering from delusional
disorder. The overriding important factor in this therapy is the quality of the
patient/therapist relationship. Trust is a key issue,  as is unconditional support. If the
client believes that the therapist really does think he or she is “crazy,” the therapy can
terminate abruptly. Early in the therapy, it is vital not to directly challenge the
delusion system or beliefs and instead to concentrate on realistic and concrete
problems and goals within the person’s life.

Once a firm, supportive therapeutic relationship has been established, the therapist
can begin reinforcing positive gains and behaviors the individual makes in his or her
life, such as in educational or occupational gains. It is important to reinforce these life
events (such as getting a job), because it reinforces in the patient a sense of self-
confidence and self-reliance.

Only when the client has begun to feel more secure in their social or occupational
world can more productive work be accomplished in therapy. This involves the
gradual but gentle challenging of the client’s delusional beliefs, starting with the
smallest and least-important items. Occasionally making these types of gentle
challenges throughout therapy will give the clinician a greater understanding of how
far along the individual has come. If the patient refuses to give up his or her delusion
beliefs, even the smallest ones, then therapy is likely to be very long-term. Even if the
client is willing, therapy is likely to take a fair amount of time, from at least 6 months
to a year.

Clinicians should always be very direct and honest, especially with people who suffer
from delusion disorder. Professionals should be even more careful than usual not to
impinge on the client’s privacy or confidentiality, and to say plainly what they mean
in therapy sessions. Subtlety and sarcasm may be easily misinterpreted by the patient.
Therapy approaches which focus on insight or self-knowledge may not be as
beneficial as those stressing social skills training and other behaviorally and solution-
oriented therapies.

Medications
Suggesting the use of medication for use in this disorder, while possibly indicated to
help temporarily relieve the delusions, is usually difficult. The client may be
suspicious of any professional suggesting the use of a medication and therefore this
treatment approach (and successful maintenance of the individual on the medication)
is problematic.

Anti-psychotic medication is the preferred medication used, though, although it is

only marginally effective. There are few studies done which confirm the use of any
specific medications for this disorder.

Hospitalization should be avoided at all costs, since this will usually go to reinforce
the individual’s distorted cognitive schema. Partial hospitalization and/or day
treatment programs are preferred to help manage the individual under close
supervision on a daily basis.

Phillip W. Long, M.D. writes that “other treatments have been tried
(electroconvulsive therapy, insulin shock therapy, and psychosurgery), but these
approaches are not recommended.”

Self-Help
There are not any self-help support groups or communities that we are aware of that
would be conducive to someone suffering from this disorder. Such approaches would
likely not be very effective because a person with this disorder is likely to be
mistrustful and suspicious of others and their motivations, making group help and
dynamics unlikely and  possibly harmful.

BRIEF PSYCHOTIC DISORDER

Brief Psychotic Disorder — also known as brief reactive psychosis —  is a mental

disorder that is typically diagnosed in a person’s late 20s or early 30s. Brief reactive
psychosis can be thought of as time-limited schizophrenia  that is resolved within one
month’s time.
It is characterized by the presence  of one or more  of the following symptoms:

 Delusions
 Hallucinations
 Disorganized speech (e.g., frequent derailment or incoherence)
 Grossly disorganized or catatonic behavior

Duration of an episode of brief psychosis is at least one day but less than one month,
with eventual full return to previous level of functioning.

The disturbance can occur as a response to extreme life stress or

withpostpartum onset. This disturbance cannot be due to the direct physiological
effects of a substance or drug (such as a prescription medication, or an illicit  drug
like cocaine), or a general medication condition.

 Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including

delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative
symptoms. Each of these symptoms may be rated for its current severity (most severe in the
last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe).

Introduction
The DSM-5 identifies Brief Psychotic Disorder as a recurrent, transient thought
disorder, which typically occurs in adolescence or young adulthood. By definition, it
is of short duration, although it can result in increased risk of suicidality, or inability
to perform self care (American Psychiatric Association, 2013). .

Symptoms of Brief Psychotic Disorder

According to the DSM-5, (Diagnostic and Statistical Manual of Mental Disorders,
fifth edition) Brief Psychotic Disorder is a thought disorder in which a person will
experience short term, gross deficits in reality testing, manifested with at least one of
the the following symptoms:
 Delusions- strange beliefs and ideas which are resistant to rational/logical dispute or contradiction
from others.
 Hallucinations- auditory, or visual.
 Disorganized Speech- incoherence, or irrational content.
 Disorganized or Catatonic behavior- repetitive, senseless movements, or adopting a pose which
may be maintained for hours. The individual may be resistant to efforts to move them into a
different posture, or will assume a new posture they are placed in (American Psychiatric
Association, 2013).
To fulfill the diagnostic criteria for Brief Psychotic Disorder, the symptoms must
persist for at least one day, but resolve in less than one month. The psychotic episode
cannot be attributed to substance use (ethanol withdrawal, cocaine abuse) or a medical
condition (fever and delirium) and the person does not fit the diagnostic criteria for
Major Depressive disorder with psychotic features, Bipolar disorder with psychotic
features, or Schizophrenia (American Psychiatric Association, 2013). .

There are five specifiers that can be used to further describe the disorder:
 With marked stressors- the psychotic episode appears following an acute stressor, or series of
stressors, which would overtax the coping skills of most individuals.
 Without marked stressors- there is no apparent stressor preceding the psychotic episode.
 Post-partum- this disorder can appear during pregnancy or within one month following childbirth.
 With catatonia.
 Severity - The clinician can rate the severity of the psychotic episode during the last seven days
using a five point scale- Zero ( Absent ) to Four ( Present and severe) (American Psychiatric
Association, 2013).

This disorder will manifest over a period of about two weeks or less, resolve in less
than one month, and the person will return to their pre-morbid level of functioning
prior to the psychotic state. (American Psychiatric Association, 2013).

Onset
This disorder is typically a response to an extreme stressor, (American Psychiatric
Association, 2013) such as combat, (Umbrasas, 2010) or a series of stressors, which
overwhelm the individual's coping skills. The DSM-5 indicates Brief Psychotic
Disorder tends to resolve within one month, and the individual typically returns to
their former level of functioning (American Psychiatric Association, 2013).

Prevalence
The DSM-5 notes Brief psychotic disorder is two times more likely to occur in
women than men, and is most commonly seen in adolescents, and young adults in
their 20's and 30's. (American Psychiatric Association, 2013) .

Risk Factors and Risk Markers

Given that Brief psychotic disorder can precipitated by stressors which overwhelm the
individual's coping skills, it can be inferred that acute or chronic stress,
underdeveloped coping skills, isolation, and lack of social supports, are risk factors.
Individuals in environments such as combat or domestic violence may be prone to
brief psychotic episodes. Trauma has been identified as a precipitant of brief
psychotic episodes (Freeman & Fowler, 2009 ; Umbrasas, 2010). The DSM-5 reports
that the presence of a Personality Disorder is also recognized as a risk factor. A
discrete diagnosis of Brief Psychotic Disorder is not warranted if the psychotic
episode is transient in one diagnosed with a personality disorder. A distinct diagnosis
of Brief Psychotic may be indicated if the episode persists for more than one day.
(American Psychiatric Association, 2013).

Co-Morbidity
Brief psychotic disorder can occur in conjunction with Borderline Personality
Disorder, or Paranoid Personality Disorder (American Psychiatric Association, 2013).

Brief Psychotic Disorder Treatment

Crisis evaluation and short term hospitalization and stabilization on anti-psychotic
meds may be required (American Psychiatric Association, 2013). CBT ( Cognitive
Behavioral therapy) to learn coping and stress reduction skills may be useful to
prevent further episodes.

Impact of Disorder on Functioning

It can be speculated that a brief psychotic episode could precipitate anxiety in the
individual over re-occurrence, or change self image. The individual may develop the
perception there is something very wrong with them, or that they are weak or
defective. They may experience social stigma, especially if they have a history of high
functioning and therefore high expectations from others. This may be especially true
if the psychotic episode cannot be rationalized in terms of a response to stress or
childbirth, but was of the Without Marked Stressors type. The DSM-5 notes high rates
of re-occurrence are typical (American Psychiatric Association, 2013).

Differential Diagnosis
The DSM-5 notes that the clinician must rule out several other conditions to make an
accurate diagnosis (American Psychiatric Association, 2013). Extended abuse of
sympathiomimetic agents ( e.g., cocaine and methamphetamine) can result in an acute
psychotic break, as can withdrawal from ethanol ( Delirium Tremens) and the use of
psychedelic agents ( e.g., LSD and psilocybin mushrooms). (Kuzenko, et al 2009).
Familiarity with the specific effects of substance use and respective withdrawal
syndromes will assist the clinician in making an appropriate differential diagnosis.
Enzyme immunoassay urine toxicology screening can also provide an objective
measure of recent substance use. Perceptual changes and delirium can also occur as a
result of dehydration or prolonged sleep deprivation. Their are numerous medical
conditions, including TBI ( Traumatic Brain Injury), which can produce psychotic
symptoms as well, which must be ruled out (Umbrasas, 2010).

It has been found that Schizophrenia can be reliably differentiated form Brief
Psychotic Disorder ( Korver-Neiberg, Quee, Boos, & Simmons, 2011). Schizophrenia
may initially present a similar diagnostic picture, but will typically not completely
resolve within less than a month, although an acute psychotic episode may be of
relatively short duration. The onset of Schizophrenia will also typically involve
negative symptoms. It should be noted that the psychotic symptoms are of a positive
presentation in the symptom dichotomy applied to psychotic disorders, and that
negative symptoms ( e.g., amotivation, anergia,) are not part of the diagnostic criteria.
A history from both the patient and collateral reports from family or friends may be
useful in determining if there have been prior psychotic episodes. Both unipolar
depression and bipolar disorder can present with psychotic features, but again, a
history can determine if there have been previous episodes. The delusional content is
noteworthy, as depressed persons are likely to have mood congruent delusions (I am
dead and rotting) and the delusional content of bipolar disorders tend to be of a
grandiose nature. The astute clinician must be aware of malingering as well,
especially in a forensic setting. There may be secondary gains for feigning mental
illness, such as diminishing criminal culpability. Cultural norms must also be
considered. What appears to be a brief psychotic state may be a within normal limits
response in some cultures, and is socially approved of and not regarded as unusual.
 
 SCHIZOPHRENIFORM DISORDER

Schizophreniform Disorder Symptoms

The characteristic symptoms of schizophreniform disorder are identical to those
of Schizophrenia, but schizophreniform disorder is distinguished by its duration. An
episode of the disorder (including prodromal, active, and residual phases) lasts at least
one month but less than 6 months.

In some cases, the diagnosis is provisional because it is unclear whether the individual
will recover from the disturbance within the 6-month period. If the disturbance
persists beyond 6 months, the diagnosis should be changed
toschizophrenia. Individuals who recover from schizophreniform disorder are
projected to have a better functional prognosis.

Another way schizophreniform disorder differs from schizophrenia is that impaired

social and occupational functioning are not required criteria. While such impairments
may potentially be present, they are not necessary for a diagnosis of schizophreniform
disorder. However, most individuals experience dysfunction in several areas of daily
functioning, such as school or work, interpersonal relationships, and self-care.

Diagnostic criteria for schizophreniform disorders requires the following symptoms

(with one being either 1, 2, or 3):

1. Delusions
2. Hallucinations (see schizophrenia for elaborated description of symptoms)
3. Disorganized speech (communication is incoherent or seems like a “word salad”; frequent
derailment of ideas)

4. Disorganized or catatonic behavior

5. Diminished range of emotional expression (the person appears emotionally withdrawn)

Introduction
Schizophreniform disorder is a part of the schizophrenia spectrum in the Diagnostic
and Statistical Manual of Mental Disorders, a psychotic condition similar in its
symptoms to schizophrenia, but developing rapidly and present for a shorter period of
time. Like the other entities in the schizophrenia spectrum, schizophreniform disorder
is a serious and often disabling mental illness with both positive and negative thought
and behavioral symptoms, demonstrable but nonspecific changes in brain anatomy,
impairment of cognitive function evident on neuropsychological testing, suggestion of
genetic predisposition and evidence of abnormal brain dopamine neurotransmission
and clinical response to dopamine-blocking neuroleptic medications and some types
of psychotherapy (Van Os & Kapur, 2009). The fifth edition of the DSM has made no
specific changes in diagnostic criteria for schizophreniform disorder but has altered
the principal criterion for diagnosis of schizophrenia itself (Criterion A) and
eliminated the various subtypes of schizophrenia previously identified (American
Psychiatric Association, 2013).

Symptoms and Prognosis of Schizophreniform

Disorder
Schizophreniform disorder and schizophrenia share many features and symptoms, but
differ in the duration of symptoms and degree of functional impairment.
Schizophrenic symptoms must be present for at least 6 months for that condition to be
diagnosed, but are by definition present for less than 6 months in schizophreniform
disorder. There is usually functional impairment (academic, occupational or social) by
the time schizophrenia is diagnosed, such difficulties may not be present at the
diagnosis of schizophreniform disorder. Schizophreniform disorder has sometimes
been a provisional diagnosis in psychotic individuals, while the condition waits to see
if symptoms improve by 6 months of illness or persist or progress to support the
impression of schizophrenia (Strakowski, 1994).

The symptoms of both disorders may be positive (hallucinations, delusions, thought

disorder and disorganized speech, behavioral disorganization or catatonia) or negative
(inability to feel emotions with flattening of affect, inability to experience pleasure or
anhedonia), loss of interest in social relationships, lack of motivation and reduction of
impairment of speech). About 2/3 of patients initially diagnosed with
schizophreniform disorder will go on to be diagnosed with schizophrenia. Several
favorable prognostic features have been identified: onset of psychotic symptoms
within 4 weeks of first noticed change in behavior or function, confusion or perplexity
during these symptoms which suggests insight into their abnormality, good
occupational and social functioning before the onset of symptoms and absence of flat
affect. Negative symptoms and lack of eye contact are unfavorable prognostic
features(Troisi et al., 1991).

Diagnostic Criteria
DSM-5 requires at least 1 of the following symptoms for a significant portion of the
time during a 1-month period: delusions, hallucinations or disorganized speech.
Grossly disorganized behavior (catatonia) or the negative symptoms described above
may also be present. Symptoms may have been present for less than a month, if they
resolved after being treated. Symptoms must last more than a month but less than 6
months. There can be no manic, depressive or mixed manic-depressive episodes
during these symptoms, and any mood disturbance must have been present during
only a minority of this time, thereby excluding schizoaffective disorder or bipolar
disorder with psychotic features. These symptoms cannot be due to the effects of a
substance (drug of abuse or medication), or to a medical or neurological disorder.
Schizophreniform disorder “with good prognostic features” is accompanied by at least
2 of the following: onset of psychotic symptoms within 4 weeks of the first noticeable
change in behavior or functioning, good social or occupational function before the
onset of symptoms, symptoms accompanied by confusion or perplexity or absence of
flat or blunted affect. The disorder is otherwise “without good prognostic features”.
Patients “with good prognostic features” may in retrospect be diagnosed with
affectrive disorders rather than conditions in the schizophrenic spectrum (Benazzi,
Mazzoli , & Rossi, 1993).

No specific DSM-5 changes were made with respect to schizophreniform disorder.

The principal criterion by which schizophrenic spectrum disorders are diagnosed
(criterion A) was modified by removing the preference (only one such symptom was
needed for the diagnosis) for bizarre delusions and what were historically called
Schneiderian first-rank auditory hallucinations (those of 2 or more voices conversing).
This was done because the Schneider symptoms have over the past century proven
diagnostically unreliable, and because the peculiarity of delusions is less important
than their specificity for this group of disorders.

Epidemiology
Schizophreniform disorder affects males and females equally, but the peak onset is
earlier in men (18-24 years) than women (24-35 years). The incidence of
schizophreniform disorder in developed countries is low, about 1/5 that of
schizophrenia in the United States. In developing countries, however, schizoaffective
disorder is diagnosed more frequently, and may be as common as schizophrenia in
some countries. Schizophreniform disorder in these countries is apparently more often
associated with good prognostic factors than in developed countries (Sautter,
McDermott, & Garver, 1993). It has been suggested that onset and recovery of
psychotic illnesses are more rapid in developing countries, which would increase the
number of patients meeting criteria for schizophreniform disorder (Jablensky et al.,
1992).

Pathophysiology
The cause(s) of the disorders in the schizophrenia spectrum are unknown, but there is
much evidence to support a disturbance in dopamine neurotransmission. Increasing
experience with the second generation or atypical neuroleptic drugs suggests that
serotonin may be involved as well (Richland et al., 2007). Patients with schizophrenia
and schizophreniform disorder also have evidence of cerebral cortical dysfunction.

Definite findings on neurological examination are infrequent in schizophrenia or

schizophreniform disorder, but “soft” neurological signs involving coordination and
involuntary movement are increased in incidence in schizophreniform disorder and
first-onset schizophrenic patients, with some evidence of a familial association and
right-sided predominance, suggesting genetic predisposition and left cerebral
hemisphere dysfunction (Bachmann, Bottmer, & Schröder, 2005). Between 5 and 80
per cent of schizophrenic patients have been reported to have slowing or paroxysmal
activity on electroencephalogram (EEG) (Hughes & John, 1999), and paroxysmal
EEG activity, not necessarily abnormal or specific, has been reported more frequently
in schizophreniform disorder than in schizophrenia itself (Inui et al., 1998).
Computer-assisted frequency analysis and topographic mapping (quantitative EEG)
has shown increased slow activity and greater interhemispheric differences than in
depressed patients or normal controls (Begic, 2011), and no difference has been
demonstrated between the disorders in the schizophrenia spectrum (Boutros, Arfken,
& Iacono, 2008).

Magnetic resonance imaging (MRI) has consistently supported the view that
schizophrenia is a brain disorder with altered structure as well as function, showing in
particular ventricular enlargement and volume loss in the temporal lobes, less
frequently the frontal lobes as well (McCarley et al., 1999). These changes are
prognostically negative in schizophrenia; they are also present in schizophreniform
disorder, but it is not clear that ventricular enlargement is a poor prognostic sign there.
Functional brain imaging with cerebral blood flow (CBF) measurement, photon
emission tomography (SPECT) and positron emission tomography (PET) has shown a
number of differences from normal, chiefly decreased frontal lobe perfusion, and
lesser and more variable degrees of hypoperfusion in parietal and left temporal lobes
in schizophreniform disorder as well as schizophrenia (Zipursky, Meyer & Verhoeff,
2007). Neuropsychological testing has shown similar patterns of deficit in
schizophrenia and schizophreniform disorder, and attentional, executive and motor
impairment at age 13 in those who developed schizophreniform disorder as adults
(Cannon et al., 2006).

Medication Treatment of Schizophreniform

Disorder
The increasingly large array of antipsychotic, antidepressant and antimanic
medications used in various combinations to treat schizophrenia is also effective in
schizophreniform disorder (Leucht et al., 2009). The treatment strategy is the same in
both conditions, and focuses on finding the lowest effective dose of neuroleptic
medication, usually an atypical antipsychotic, with prevention if possible of
extrapyramidal side effects. Symptoms resistant to second-generation neuroleptics are
usually addressed with newer antipsychotic medications or the addition of lithium,
SSRI or SNRI antidepressants or mood-stabilizing anticonvulsants (Sajatovic et al.,
2002). Electroconvulsive therapy is occasionally effective for treatment-resistant
symptoms (Stromgren, 1988).

Risperidone (Risperdal), quetiapine (Seroquel), olanzapine (Zyprexa) and ziprasidone

(Geodon) are the most commonly-used atypical neuroleptics, so called because they
do not work solely by blockade of the D2 dopamine receptors as the first-generation
or typical neuroleptics like chlorpromazine or haloperidol do. These are about equal
in efficacy for schizophrenia and schizoaffective disorder, but may be more effective
and better tolerated in lower doses for first-time psychotic symptoms as in
schizophreniform disorder (Sanger et al., 1999). A new generation of neuroleptics is
effective for resistant psychotic symptoms: aripiperazole (Abilify), which is a partial
agonist rather than blocker of dopamine receptors and can be given by injection;
paliperidone (Invega), the active metabolite of risperidone which can be given once
daily; asenapine (Saphris), a relative of the antidepressant mirtazapine that must be
taken sublingually but may also help mania and depression; iloperidone (Zomaril),
which antagonizes serotonin as well as dopamine and my cause fewer problems with
weight gain and extrapyramidal side effects; and lurasidone (Latuda), which is helpful
for bipolar depression as well as psychosis.

Schizophreniform disorder accompanied by depressive symptoms is usually treated

with an SSRI or SNRI antidepressant plus one of the above antipsychotics. If manic
symptoms accompany the psychosis, mood stabilizers (lithium carbonate,
carbamazepine, valproic acid, lamotrigine or topiramate) can be added. Clozapine,
highly effective and free of extrapyramidal complications but attended by
agranulocytosis, has been used for refractory psychosis but carries several “black
box” warnings and requires regular blood and absolute neutrophil counts.

SCHIZOAFFECTIVE DISORDER

DSM-5 diagnostic criteria for

schizoaffective disorder3
A. An uninterrupted period of illness during which there is a major mood episode (major depressive
or manic) concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode
(depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total
duration of the active and residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
Bipolar type: This subtype applies if a manic episode is part of the presentation.
Major depressive episodes may also occur.
Depressive type: This subtype applies if only major depressive episodes are part
of the presentation.

Schizoaffective Disorder is characterized by the presence of a generally continuous

psychotic illness plus intermittent mood episodes. Mood episodes are present for the
majority of the total duration of the illness, which can include either one or both of
the following:

 Major Depressive Episode (must include depressed mood)

 Manic Episode

The psychotic illness criteria resembles criterion A of the schizophreniadiagnosis.

requiring at least two of the following symptoms, for at least one month:

 Delusions

 Hallucinations

 Disorganized speech (e.g., frequent derailment or incoherence)

 Grossly disorganized or catatonic behavior

 Negative symptoms (e.g., affective flattening, alogia, avolition)

(Only one symptom is required if delusions are bizarre or hallucinations consist of a

voice keeping up a running commentary on the person’s behavior or thoughts, or two
or more voices conversing with each other.)

The occurrence of the delusions or hallucinations must be in the absence of any

serious mood symptoms for at least 2 weeks. The mood disorder, however, must be
present for a significant minority of the time. The symptoms of this disorder also can
not be better explained by the use or abuse of a substance (alcohol,
drugs, medications) or a general medical condition (stroke). If the mood symptoms
are present for only a relatively brief period, the diagnosis isschizophrenia, not
schizoaffective disorder. Occupational functioning is frequently impaired, but this is
not a defining criterion (in contrast to schizophrenia). Restricted social contact and
difficulties with self-care are associated with schizoaffective disorder, but negative
symptoms may be less severe and less persistent than those seen in schizophrenia.
Schizoaffective disorder is less common than schizophrenia.