Amity Institute of Psychology & Allied Sciences

Individual Psychotherapy (PSYC784)

Module-II
Schizophrenia Spectrum & Other Psychotic
Disorder

-Dr. Anu Teotia

Assistant Professor (AIPS)
Certified Psychotherapist
 Schizophrenia Spectrum & Other Psychotic
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Disorder
Schizophrenia spectrum and other psychotic disorders include
schizophrenia, other psychotic disorders, and schizotypal
(personality) disorder.

They are defined by abnormalities in one or more of the

following five domains: delusions, hallucinations,
disorganized thinking (speech), grossly disorganized or
abnormal motor behaviour (including catatonia), and
negative symptoms.
 Delusions
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Fixed beliefs that are not amenable to change in light of

conflicting evidence.

• Persecutory delusions - belief that one is going to be harmed,

harassed, and so forth by an individual, organization, or other
group.

• Referential delusions -belief that certain gestures, comments,

environmental cues, and so forth are directed at oneself.

• Grandiose delusions -when an individual believes that he or

she has exceptional abilities, wealth, or fame.
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Erotomanic delusions - when an individual believes falsely that

another person is in love with him or her.

Nihilistic delusions -involve the conviction that a major

catastrophe will occur.

Somatic delusions- focus on preoccupations regarding health

and organ function.

Delusions that express a loss of control over mind or body are generally
considered to be bizarre; these include the belief that one's thoughts
have been "removed" by some outside force {thought withdrawal), that
alien thoughts have been put into one's mind (thought insertion), or
that delusions of control). one's body or actions are being acted on or
manipulated by some outside force .
 Hallucinations
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Perception-like experiences that occur without an external

stimulus.

They are vivid and clear, with the full force and impact of normal
perceptions, and not under voluntary control. They may occur in any
sensory modality, but auditory hallucinations are the most common in
schizophrenia and related disorders.
Auditory hallucinations are usually experienced as voices, whether
familiar or unfamiliar, that are perceived as distinct from the
individual's own thoughts.

those that occur while falling asleep (hypnagogic) or waking up

(hypnopompic) are considered to be within the range of normal
experience.
 Disorganized Thinking (Speech)
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The individual may switch from one topic to another {derailment or

loose associations). Answers to questions may be obliquely
related or completely unrelated (tangentiality).
Rarely, speech may be so severely disorganized that it is nearly
incomprehensible and resembles receptive aphasia in its linguistic
disorganization {incoherence or "word salad"). Because mildly
disorganized speech is common and nonspecific, the symptom
must be severe enough to substantially impair effective
communication. The severity of the impairment may be difficult to
evaluate if the person making the diagnosis comes from a
different linguistic background than that of the person being
examined. Less severe disorganized thinking or speech may
occur during the prodromal and residual periods of schizophrenia.
 Delusional Disorder
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A. The presence of one (or more) delusions with a duration of

1 month or longer.

B. Criterion A for schizophrenia has never been met. Note:

Hallucinations, if present, are not prominent and are
related to the delusional theme (e.g., the sensation of
being infested with insects associated with delusions of
infestation).

C. Apart from the impact of the delusion(s) or its ramifications,

functioning is not markedly impaired, and behavior is not
obviously bizarre or odd.
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D. If manic or major depressive episodes have occurred, these

have been brief relative to the duration of the delusional
periods.

E. The disturbance is not attributable to the physiological

effects of a substance or another medical condition and is not
better explained by another mental disorder, such as body
dysmorphic disorder or obsessive-compulsive disorder.
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Specify whether:

Erotomaniac type: This subtype applies when the central theme

of the delusion is that another person is in love with the
individual.

Grandiose type: This subtype applies when the central theme of

the delusion is the conviction of having some great (but
unrecognized) talent or insight or having made some important
discovery.

Jealous type: This subtype applies when the central theme of

the individual’s delusion is that his or her spouse or lover is
unfaithful.
 Amity Institute of Psychology & Allied Sciences

Persecutory type: This subtype applies when the central theme

of the delusion involves the individual’s belief that he or she is
being conspired against, cheated, spied on, followed, poisoned
or drugged, maliciously maligned, harassed, or obstructed in the
pursuit of long-term goals.

Somatic type: This subtype applies when the central theme of

the delusion involves bodily functions or sensations.
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Mixed type: This subtype applies when no one delusional

theme predominates.

Unspecified type: This subtype applies when the dominant

delusional belief cannot be clearly determined or is not
described in the specific types (e.g., referential delusions
without a prominent persecutory or grandiose component).

Specify if:

With bizarre content: 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).
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Specify if:

The following course specifiers are only to be used after a 1 -year

duration of the disorder:

First episode, currently in acute episode: First manifestation of

the disorder meeting the defining diagnostic symptom and time
criteria. An acute episode is a time period in which the symptom
criteria are fulfilled.

First episode, currently in partial remission: Partial remission

is a time period during which an improvement after a previous
episode is maintained and in which the defining criteria of the
disorder are only partially fulfilled.
 Amity Institute of Psychology & Allied Sciences

First episode, currently in full remission: Full remission is a

period of time after a previous episode during which no disorder-
specific symptoms are present.

Multiple episodes, currently in acute episode

Multiple episodes, currently in partial remission

Multiple episodes, currently in full remission

Continuous: Symptoms fulfilling the diagnostic symptom criteria

of the disorder are remaining for the majority of the illness
course, with subthreshold symptom periods being very brief
relative to the overall course.
 Amity Institute of Psychology & Allied Sciences

Specify current severity: 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).

Note: Diagnosis of delusional disorder can be made without

using this severity specifier.
 Differential Diagnosis
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Obsessive-compulsive and related disorders-

If an individual with obsessive-compulsive disorder is completely

convinced that his or her obsessive-compulsive disorder beliefs
are true, then the diagnosis of obsessive-compulsive disorder,
with absent insight/delusional beliefs specifier, should be given
rather than a diagnosis of delusional disorder.

Similarly, if an individual with body dysmorphic disorder is

completely convinced that his or her body dysmorphic disorder
beliefs are true, then the diagnosis of body dysmorphic disorder,
with absent insight/delusional beliefs specifier, should be given
rather than a diagnosis of delusional disorder.
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Delirium, major neurocognitive disorder, psychotic disorder

due to another medical condition, and substance/medication-
induced psychotic disorder-

Individuals with these disorders may present with symptoms that

suggest delusional disorder. For example, simple persecutory
delusions in the context of major neurocognitive disorder would be
diagnosed as major neurocognitive disorder, with behavioral
disturbance.

A substance/ medication-induced psychotic disorder cross-

sectionally may be identical in symptomatology to delusional
disorder but can be distinguished by the chronological relationship
of substance use to the onset and remission of the delusional
beliefs.
 Amity Institute of Psychology & Allied Sciences

Schizophrenia and schizophreniform disorder-

Delusional disorder can be distinguished from schizophrenia and

schizophreniform disorder by the absence of the other
characteristic symptoms of the active phase of schizophrenia.

Depressive and bipolar disorders and schizoaffective

disorder-

These disorders may be distinguished from delusional disorder by

the temporal relationship between the mood disturbance and the
delusions and by the severity of the mood symptoms. If delusions
occur exclusively during mood episodes, the diagnosis is
depressive or bipolar disorder with psychotic features.
 Amity Institute of Psychology & Allied Sciences

Mood symptoms that meet full criteria for a mood episode can be
superimposed on delusional disorder. Delusional disorder can be
diagnosed only if the total duration of all mood episodes remains
brief relative to the total duration of the delusional disturbance.

If not, then a diagnosis of other specified or unspecified

schizophrenia spectrum and other psychotic disorder
accompanied by other specified depressive disorder, unspecified
depressive disorder, other specified bipolar and related disorder,
or unspecified bipolar and related disorder is appropriate.
 Brief Psychotic Disorder
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A. Presence of one (or more) of the following symptoms. At least

one of these must be (1), (2), or (3):

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.

Note: Do not include a symptom if it is a culturally sanctioned

response. B. Duration of an episode of the disturbance is at least
1 day but less than 1 month, with eventual full return to
premorbid level of functioning.
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C. The disturbance is not better explained by major depressive

or bipolar disorder with psychotic features or another psychotic
disorder such as schizophrenia or catatonia, and is not
attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition.

Specify if:

With marked stressor(s) (brief reactive psychosis): If

symptoms occur in response to events that, singly or together,
would be markedly stressful to almost anyone in similar
circumstances in the individual’s culture.
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Without marked stressor(s): If symptoms do not occur in

response to events that, singly or together, would be
markedly stressful to almost anyone in similar circumstances
in the individual’s culture.

With postpartum onset: If onset is during pregnancy or

within 4 weeks postpartum.

Specify if:

With catatonia
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Specify current severity: 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).
 Prevalence
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The lifetime prevalence of delusional disorder has been

estimated at around 0.2%.

The most frequent subtype is persecutory. Delusional

disorder, jealous type, is probably more common in males
than in females, but there are no major gender differences
in the overall frequency of delusional disorder.
 Brief Psychotic Disorder
Amity Institute of Psychology & Allied Sciences

A. Presence of one (or more) of the following symptoms. At least

one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
Note: Do not include a symptom if it is a culturally sanctioned
response.

B. Duration of an episode of the disturbance is at least 1 day but

less than 1 month, with eventual full return to premorbid level of
functioning.
 Amity Institute of Psychology & Allied Sciences

C. The disturbance is not better explained by major depressive or bipolar

disorder with psychotic features or another psychotic disorder such as
schizophrenia or catatonia, and is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or another
medical condition.

Specify if:

With marked stressor(s) (brief reactive psychosis): If symptoms occur

in response to events that, singly or together, would be markedly
stressful to almost anyone in similar circumstances in the individual’s
culture.
 Amity Institute of Psychology & Allied Sciences

Without marked stressor(s): If symptoms do not occur in response to

events that, singly or together, would be markedly stressful to almost
anyone in similar circumstances in the individual’s culture. With
postpartum onset: If onset is during pregnancy or within 4 weeks
postpartum.

Specify if:
With catatonia
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Specify current severity:

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).
 Prevalence
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In the United States, brief psychotic disorder may account for 9% of

cases of first-onset psychosis.

Psychotic disturbances that meet Criteria A and C, but not Criterion B,

for brief psychotic disorder (i.e., duration of active symptoms is 1-6
months as opposed to remission within 1 month) are more common in
developing countries than in developed countries.

Brief psychotic disorder is twofold more common in females than in

males
 Risk and Prognostic Factors
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Temperamental-
Preexisting personality disorders and traits (e.g., schizotypal
personality disorder; borderline personality disorder; or traits
in the psychoticism domain, such as perceptual
dysregulation, and the negative affectivity domain, such as
suspiciousness) may predispose the individual to the
development of the disorder.
 Schizophreniform Disorder
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A. Two (or more) of the following, each present for a significant portion
of time during a 1-month period (or less if successfully treated). At
least one of these must be (1), (2), or (3):
1. Delusions.

2. Hallucinations.

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

4. Grossly disorganized or catatonic behavior.

5. Negative symptoms (i.e., diminished emotional expression or

avolition)
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B. An episode of the disorder lasts at least 1 month but less than 6

months. When the diagnosis must be made without waiting for recovery,
it should be qualified as “provisional.” ‘

C. Schizoaffective disorder and depressive or bipolar disorder with

psychotic features have been ruled out because either 1 ) no major
depressive or manic episodes have occurred concurrently with the active-
phase symptoms, or 2) if mood episodes have occurred during active-
phase symptoms, they have been present for a minority of the total
duration of the active and residual periods of the illness.

D. The disturbance is not attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication) or another medical
condition.
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Specify if:

With good prognostic features: This specifier requires the presence of

at least two of the following features: onset of prominent psychotic
symptoms within 4 weeks of the first noticeable change in usual
behavior or functioning; confusion or perplexity: good premorbid social
and occupational functioning; and absence of blunted or flat affect.

Without good prognostic features: This specifier is applied if two or

more of the above features have not been present.

Specify if:

With catatonia
 Amity Institute of Psychology & Allied Sciences

Specify current severity: 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).
 Development and CourseAmity Institute of Psychology & Allied Sciences

The development of schizophreniform disorder is similar to that of

schizophrenia. About one-third of individuals with an initial
diagnosis of schizophreniform disorder (provisional) recover within
the 6-month period and schizophreniform disorder is their final
diagnosis.

The majority of the remaining two-thirds of individuals will

eventually receive a diagnosis of schizophrenia or schizoaffective
disorder.
 Risk and Prognostic Factors
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Genetic and physiological.

Relatives of individuals with schizophreniform disorder have an

increased risk for schizophrenia.
 Schizophrenia
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A. Two (or more) of the following, each present for a significant

portion of time during a 1 -month period (or less if successfully
treated). At least one of these must be (1 ), (2), or (3):

1. Delusions.

2. Hallucinations.

3. Disorganized speech (e.g., frequent derailment or

incoherence).

4. Grossly disorganized or catatonic behavior. 5. Negative

symptoms (i.e., diminished emotional expression or avolition).
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B. For a significant portion of the time since the onset of the disturbance,
level of functioning in one or more major areas, such as work,
interpersonal relations, or self-care, is markedly below the level achieved
prior to the onset (or when the onset is in childhood or adolescence, there
is failure to achieve expected level of interpersonal, academic, or
occupational functioning).

C. Continuous signs of the disturbance persist for at least 6 months. This

6-month period must include at least 1 month of symptoms (or less if
successfully treated) that meet Criterion A (i.e., active-phase symptoms)
and may include periods of prodromal or residual symptoms. During
these prodromal or residual periods, the signs of the disturbance may be
manifested by only negative symptoms or by two or more symptoms
listed in Criterion A present in an attenuated form (e.g., odd beliefs,
unusual perceptual experiences).
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D. Schizoaffective disorder and depressive or bipolar disorder with

psychotic features have been ruled out because either 1 ) no major
depressive or manic episodes have occurred concurrently with the active-
phase symptoms, or 2) if mood episodes have occurred during active-
phase symptoms, they have been present for a minority of the total
duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication) or another medical
condition.
F. 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 of schizophrenia, are also present for at least 1
month (or less if successfully treated).
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Specify if: The following course specifiers are only to be used

after a 1-year duration of the disorder and if they are not in
contradiction to the diagnostic course criteria.

First episode, currently in acute episode: First manifestation

of the disorder meeting the defining diagnostic symptom and
time criteria. An acute episode is a time period in which the
symptom criteria are fulfilled.

First episode, currently in partial remission: Partial

remission is a period of time during which an improvement after
a previous episode is maintained and in which the defining
criteria of the disorder are only partially fulfilled.
 Amity Institute of Psychology & Allied Sciences
First episode, currently in full remission: Full remission is a period of
time after a previous episode during which no disorder-specific
symptoms are present.

Multiple episodes, currently in acute episode: Multiple episodes may

be determined after a minimum of two episodes (i.e., after a first
episode, a remission and a minimum of one relapse).

Multiple episodes, currently in partial remission

Multiple episodes, currently in full remission

Continuous: Symptoms fulfilling the diagnostic symptom criteria of the

disorder are remaining for the majority of the illness course, with
subthreshold symptom periods being very brief relative to the overall
course.
 Amity Institute of Psychology & Allied Sciences

Unspecified

Specify if:

With catatonia

Specify current severity: 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).
 Prevalence
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The lifetime prevalence of schizophrenia appears to be approximately

0.3%-0.7%, although there is reported variation by race/ethnicity, across
countries, and by geographic origin for immigrants and children of
immigrants.

The sex ratio differs across samples and populations: for example, an
emphasis on negative symptoms and longer duration of disorder
(associated with poorer outcome) shows higher incidence rates for
males, whereas definitions allowing for the inclusion of more mood
symptoms and brief presentations (associated with better outcome) show
equivalent risks for both sexes
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Thank you!