1.

01B  
August  17,  2017  
SCHIZOPHRENIA,  SCHIZOPHRENIFORM,  BRIEF  PSYCHOTIC  &  DELUSIONAL  DISORDERS  

Jose  Gerardo  Los  Baños,  M.D.  

Department  of  Psychiatry  

PSYCHIATRY  II  SCHIZOPHRENIFORM  AND  OTHER   Diagnostic  Features  

DISORDERS   The  diagnosis  of  schizophreniform  disorder  is  made  under  two  
Schizophreniform  Disorder   conditions.    
Diagnostic  Criteria   1) An  episode  of  illness  lasts  between  1  and  6  months  and  
A.  Two  (or  more)  of  the  following,  each  present  for  a  significant   the  individual  has  already  recovered,  and    
portion  of  time  during  a  1-­‐month  period  (or  less  if  successfully   2) Individual  is  symptomatic  for  less  than  the  6  months'  
treated).   duration  required  for  the  diagnosis  of  schizophrenia  but  
1.  Delusions   has  not  yet  recovered.    
2.  Hallucinations   •  In  this  case,  the  diagnosis  should  be  noted  as  "schizophreniform  
disorder  (provisional)"  because  it  is  uncertain  if  the  individual  
3.  Disorganized  speech  
will  recover  from  the  disturbance  within  the  6-­‐month  period.    
4.  Grossly  disorganized  or  catatonic  behavior  
•  If  the  disturbance  persists  beyond  6  months,  the  diagnosis  
5.  Negative  symptoms  (e.g.,  diminished  emotional   should  be  changed  to  schizophrenia.    
expression  or  avolition  
•  Another  distinguishing  feature  of  schizophreniform  disorder  is  
  the  lack  of  a  criterion  requiring  impaired  social  and  occupational  
B.  An  episode  of  the  disorder  lasts  at  least  1  month  but  less   functioning.    
than  6  months.   •  While  such  impairments  may  potentially  be  present,  they  are  
• When  the  diagnosis  must  be  made  without  waiting  for   not  necessary  for  its  diagnosis.    
recovery  it  should  be  qualifies  as  “provisional.”   •  In  addition  to  the  five  symptom  domain  areas  identified  in  the  
-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐DSM  V-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐   diagnostic  criteria,  the  assessment  of  cognition,  depression,  and  
C.  Schizoaffective  disorder  and  depressive  or  bipolar  disorder   mania  symptom  domains  is  vital  for  making  critically  important  
with  psychotic  features  have  been  ruled  out  because     distinctions  between  the  various  schizophrenia  spectrum  and  
• no  major  depressive  or  manic  episodes  have  occurred   other  psychotic  disorder.  
concurrently  with  the  active-­‐phase  symptoms,  or    
• 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.  
Specify  if:  
With  good  prognostic  features:  This  specifier  requires  
the  presence  of  at  least  two  of  the  following  features:    
1. onset   of   prominent   psychotic   symptoms   within   4  
weeks   of   the   first   noticeable   change   in   usual  
behavior  or  functioning;  
2. confusion  or  perplexity:  good  premorbid  social  and  
occupational  functioning;  and    
3. 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    
 
Specify  current  severity:  
Severity  is  rated  by  a  quantitative  assessment  of  the  primary  
symptoms  (same  as  in  Brief  Psychotic  Disorder)  
 
 
 

1  of  x  
[Capalaran,  De  Gracia,  Dungca,  Maki,  Zaguirre]
 Associated  Features  Supporting  Diagnosis   4. Grossly  disorganized  or  catatonic  behavior  
• No  laboratory  or  psychometric  tests  for  schizophreniform   Note:   Do   not   include   a   symptom   if   it   is   a   culturally  
disorder.   sanctioned  response  
B. Duration   of   an   episode   of   the   disturbance   is   at   least   1   day  
• There  are  multiple  brain  regions  where  neuroimaging,  
neuropathological,  and  neurophysiological  research  has   but   less   than   1   month,   with   eventual   full   return   to  
premorbid  level  of  functioning.  
indicated  abnormalities,  but  none  are  diagnostic.  
C. The   disturbance   is   not   better   explained   by   major   depressive  
 
or   bipolar   disorder   w/   psychotic   features   or   another  
Development  and  Course   psychotic  disorder  such  as  schizophrenia  or  catatonia  
• Development  is  similar  to  that  of  schizophrenia   4. not   attributable   to   the   physiological   effects   of   a  
o About  1/3  of  individuals  with  an  initial  diagnosis  of   substance   (e.g.,   a   drug   of   abuse,   a   medication)   or  
schzophreniform  disorder  (provisional)  recover  within  6-­‐ another  medical  condition  
month  period  and  schizophreniform  disorder  is  their  final   -­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐DSM  V-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐  
diagnosis.   Specify  if:  
o Majority  of  the  remaining  2/3  will  receive  a  diagnosis  of   o With  marked  stressor(s)  (brief  reactive  psychosis):  
schizophrenia/  schizoaffective  d/o.   § Symptoms   occur   in   response   to   events   that,   singly   or  
• Clinical  features   together,   would   be   markedly   stressful   to   almost   anyone  
o Favorable  course:  presence  of  affective   in  similar  circumstance  in  the  individual’s  culture  
symptoms   o Without  marked  stressor(s)  
§ Symptoms   do   not   occur   in   response   to   events   that,  
o Unfavorable  course:  flat  or  blunt  affect  
singly   or   together,   would   be   markedly   stressful   to  
Risk  and  Prognostic  Factors  
almost   anyone   in   similar   circumstance   in   the  
Genetic  and  physiological   individual’s  culture.  
o Relatives  of  individuals  with  schizophreniform  disorder   o With  postpartum  onset  
have  an  increased  risk  for  schizophrenia.   § Onset  is  during  pregnancy  or  4  weeks  postpartum  
   
Differential  Diagnosis   Specify   if   with   catatonia   (refer   to   the   criteria   for   catatonia  
associated  with  other  mental  disorder)  
Other  mental  disorder  and  medical  conditions  
 
o Psychotic  disorder  d/t  another  medical  condition  or  its  
Specify  current  severity:  
treatment;  
o Rated   by   rated   by   a   quantitative   assessment   of   the  
o Delirium  or  major  neurocognitive  disorder   primary   symptoms   of   psychosis,   including   delusions,  
o Substance/medication-­‐induced  psychotic  disorder  or   hallucinations,   disorganized   speech,   abnormal  
delirium   psychomotor  behavior,  and  negative  symptoms  
o Depressive  or  bipolar  disorder  with  psychotic  features   Each   of   these   symptoms   may   be   rated   for   its   current   severity  
o Schizoaffective  disorder   (most   severe   in   the   last   7   days)   on   a   5-­‐point   scale   ranging  
o Other  specified  or  unspecified  bipolar  and  related   from  0  (not  present)  to  4  (present  and  severe)  
disorder    
o Depressive  or  bipolar  disorder  with  catatonic  features   Diagnostic  Features  
o Schizophrenia   • Brief   psychotic   disorder   is   an   acute   and   transient  
o Brief  psychotic  disorder   psychotic  syndrome  
o Delusional  disorder   • Psychotic   symptoms   last   at   least   1   day   but   less   than   1  
o Other  specified  or  unspecified  schizophrenia  spectrum   month  
and  other  psychotic  disorder   • Not   associated   with   a   mood   disorder,   a   substance-­‐
o Schizotypal,  schizoid,  or  paranoid  personality  disorder   related   disorder,   or   a   psychotic   disorder   caused   by   a   general  
o Autism  Spectrum  Disorder   medical  condition.    
o Disorders  presenting  in  childhood  with  disorganized   • There  are  three  subtypes  of  brief  psychotic  disorder:    
(C.1) The  presence  of  a  stressor,    
speech  
(C.2) The  absence  of  a  stressor,  and    
o ADHD  
(C.3) A  postpartum  onset  
o OCD    
o PTSD   Associated  Features  Supporting  Diagnosis  
o Traumatic  brain  injury   • Typically   experience   emotional   turmoil   or   overwhelming  
  confusion.  
Brief  Psychotic  Disorder   Although   disturbance   is   brief,   level   of   impairment   may  
Diagnostic  Criteria   be  severe  
A. Presence   of   one   (or   more)   of   the   following   symptoms.   At   5. Supervision   may   be   required   to   ensure   that  
least  one  of  there  (1),  (2),  (3):   nutritional  and  hygienic  needs  are  met  
1. Delusions   Increased   risk   of   suicidal   behavior   particularly   during  
2. Hallucinations   the  acute  episode  
3. Disorganized   speech   (e.g.,   frequent   derailment   or    
incoherence)   Clinical  Features    
2  of  x  
[Capalaran,  De  Gracia,  Dungca,  Maki,  Zaguirre]
• No  negative  symptoms  (Doc  Joge)   o May  have  the  appearance  of  brief  psychotic  disorder,  
• An  abrupt  onset,  but  do  not  always  include  the  entire  symptom   but  in  such  cases  there  is  evidence  that  the  symptoms  
pattern  seen  in  schizophrenia   are  intentionally  produced.    
• Some  clinicians  have  observed  labile  modd,  confusion,  and   o When  malingering  involves  apparently  psychotic  
impaired  attention   symptoms,  there  is  usually  evidence  that  the  illness  is  
• Characteristic  symptoms  include:   being  feigned  for  an  understandable  goal.    
o Emotional  volatility   • Substance-­‐related  Disorders  
o Strange  or  bizarre  behavior   • Other  psychotic  disorders  
o Screaming  or  muteness    
o Impaired  memory  of  recent  events   Schizoaffective  Disorder  
  Diagnostic  Criteria  
Course  and  Prognosis   A. An  uninterrupted  period  of  illness  during  which  there  is  a  
major   mood   episode   (major   depressive   or   manic)  
• The  course  of  brief  psychotic  disorder  is  less  than  1  month  
concurrent  with  Criterion  A  of  schizophrenia.  
• Patients  with  brief  psychotic  disorder  generally  have  good   Note:   The   major   depressive   episode   must   include   Criterion   A1:  
prognoses   Depressed  mood  
• 50  to  80%  of  all  patients  have  no  further  major   B. Delusions   or   hallucinations   for   2   or   more   weeks   in   the  
psychiatric  problems   absence   of   a   major   mood   episode   (depressive   or   manic)  
• The  length  of  the  acute  and  residual  symptoms  is  often  just  a   during  the  lifetime  duration  of  the  illness.  
few  days    
• Occasionally,  depressive  symptoms  follow  the  resolution  of  the   -­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐DSM  V-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐  
psychotic  symptoms   C. Symptoms   that   meet   criteria   for   a   major   mood   episode   are  
• Suicide  is  a  concern  during  both  the  psychotic  phase  and  the   present   for   the   majority   of   the   total   duration   of   the   active   and  
post  psychotic  depressive  phase.   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  
Good  Prognostic  Features  for  Brief  Psychotic  Disorder    
medical  condition.  
   
• Good  premorbid  adjustment   Specify  whether:  
• Few  premorbid  schizoid  traits   6. Bipolar   type:   This   subtype   applies   if   a   manic  
• Severe  precipitating  stressors   episode  is  part  of  the  presentation.  
• Sudden  onset  of  symptoms   1. Major  depressive  episodes  may  also  occur.  
• Affective  sympotms   7. Depressive   type:   This   subtype   applies   if   only  
major   depressive   episodes   are   part   of   the  
• Confusion  and  perplexity  during  psychosis  
presentation.  
• Little  affective  blunting    
• Short  duration  of  symptoms   Specify   if   with   catatonia   (refer   to   the   criteria   for   catatonia  
• Absence  of  schizophrenic  relative   associated  with  other  mental  disorder)  
  • Coding   note:   use   additional   code   catatonia   associated  
Differential  Diagnosis   with   brief   psychotic   disorder   to   indicate   the   presence   of  
comorbid  catatonia  
• Substance-­‐related  disorders  –  a  substance  (e.g.  a  drug   Specify  if:  
abuse  or  medication)  is  judged  to  be  etiologically  related  to   • The  following  course  specifiers  are  only  to  be  used  after  a  1  -­‐
the  psychotic  symptoms.  Laboratory  tests  may  be  helpful  (e.g.   year   duration   of   the   disorder   and   if   they   are   not   in  
urine  testing  for  alcohol  screening)   contradiction  to  the  diagnostic  course  criteria.  
• Pychotic  disorder  d/t  another  medical  conditions  –   1. First  episode,  currently  in  acute  episode:    
diagnosed  when  there  is  evidence  (from  history,  PE,   § First   manifestation   of   the   disorder   meeting   the  
laboratory  tests)  that  the  psychosis  are  direct  physiological   defining  diagnostic  symptom  and  time  criteria.  
consequence  of  a  specific  medical  condition.   § An   acute   episode   is   a   time   period   in   which   the  
• Depressive  and  Bipolar  Disorders-­‐  diagnosis  of  brief   symptom  criteria  are  fulfilled.  
psychotic  disorder  cannot  be  made  when  it  is  better   2. First   episode,   currently   in   partial  
explained  by  a  mood  episode.   remission:    
• Personality  Disorders-­‐  psychosocial  stressors  may   § Partial   remission   is   a   time   period   during   which   an  
precipitate  brief  periods  of  psychotic  symptoms.  These   improvement  after  a  previous  episode  is  maintained  
symptoms  are  usually  transient  and  do  not  warrant  a   § The   time   period   in   which   the   defining   criteria   of   the  
separate  diagnosis.  If  psychotic  symptoms  persist  for  at  least   disorder  are  only  partially  fulfilled.  
1  day,  and  additional  diagnosis  of  brief  psychotic  disorder   3. First  episode,  currently  in  full  remission:    
may  be  appropriate.   § Full   remission   is   a   period   of   time   after   a   previous  
• Malingering  and  Factitious  Disorders   episode   during   which   no   disorder-­‐specific  
symptoms  are  present.  

3  of  x  
[Capalaran,  De  Gracia,  Dungca,  Maki,  Zaguirre]
 4. Multiple   episodes,   currently   in   acute   Etiology  
episode:     Cause  unknown.  
§ Multiple   episodes   may   be   determined   after   a   May  be  a  type  of:  
minimum  of  two  episodes  (i.e.,  after  a  first  episode,   8. Schizophrenia  
a  remission  and  a  minimum  of  one  relapse)   9. Mood  disorder  
5. Multiple   episodes,   currently   in   partial   10. The  simultaneous  expression  of  each  
remission   May  also  be  a  distinct  3rd  type  of  psychosis  
6. Multiple   episodes,   currently   in   full   11. One  that  is  unrelated  to  schizo  or  mood  d/o.  
remission   A   heterogeneous   group   of   d/o   encompassing   all   of   the   above  
7. Continuous:   possibilities.  
§ Symptoms  fulfilling  the  diagnostic  symptom  criteria   Studies  of  the  disrupted  in  schizophrenia  1  (DISC1)  gene,  located  
of   the   disorder   are   remaining   for   the   majority   of   the   on   chromosome   1q42,   suggest   its   possible   involvement   in  
illness  course   schizoaffective  disorder  as  well  as  schizophrenia  and  bipolar  
§ With   subthreshold   symptom   periods   being   very   disorder.  
brief  relative  to  the  overall  course.   Patients  prognosis  :  
8. Unspecified   12. Better  that  schizo,  worse  than  mood  d/o  
  13. Mood  d/o  >  Schizoaffective  >  Schizophrenia  
Specify  current  severity:   Have   nondeteriorating   course   and   respond   better   to   lithium   than  
• Severity   is   rated   by   a   quantitative   assessment   of   the   primary   schizophrenia  
symptoms  of  psychosis  inclusing:    
o Delusions   Course  and  Prognosis  
o Hallucinations  
• It   has   been   presumed   that   an   increasing   presence   of  
o Disorganized  speech  
schizophrenic  symptoms  predicted  a  worse  prognosis.    
o Abnormal  psychomotor  behaviour  
• Predominant   symptoms   were   affective   (better  
o Negative  symptoms  
prognosis)  or  schizophrenic  (worse  prognosis).    
• Each  of  these  symptoms  may  be  rated  for  its  current  severity  
• One   study   that   followed   patients   diagnosed   with  
o most  severe  in  the  last  7  days  
schizoaffective  disorder  for  8  years  found  that  the  outcomes  
o on  a  5-­‐point  scale  ranging  from  0  to  4  
of  these  patients  more  closely  resembled  schizophrenia  than  
§ 0  (not  present)  
mood  disorder  with  psychotic  features.  
4  (present  and  severe)  
 
• Typical  age  at  onset:  Early  adulthood  
Clinical  Features   o Although   can   occur   anywhere   from   adolescence   to   late  
• Schizoaffective   disorder   has   features   of   both   in  life.  
schizophrenia  and  mood  disorders.     • May  occur  in  a  variety  of  temporal  patterns  
• Patients   can   receive   the   diagnosis   of   schizoaffective    
disorder  if  they  fit  into  one  of  the  following  six  categories:     • The  typical  pattern:    
(1) With  schizophrenia  who  have  mood  symptoms   o An   individual   may   have   pronounced  
(2) With  mood  disorder  who  have  symptoms  of   auditory   hallucinations   and   persecutory  
schizophrenia   delusions   for   2   months   before   the   onset   of   a  
(3) With  both  mood  disorder  and  schizophrenia   prominent  major  depressive  episode.  
(4) With  a  third  psychosis  unrelated  to   o The  psychotic  symptoms  and  the  full  major  
schizophrenia  and  mood  disorder   depressive  episode  are  then  present  for  3  months.  
(5) Whose  disorder  is  on  a  continuum  between   o Then,   the   individual   recovers   completely  
schizophrenia  and  mood  disorder   from   the   major   depressive   episode,   but   the  
(6) With  some  combination  of  the  above   psychotic   symptoms   persist   for   another   month  
before  they  too  disappear.    
• The  length  of  each  episode  is  critical  for  two  reasons:   o During   this   period   of   illness,   the   individual's  
o To  meet  the  Criterion  B  (psychotic  symptoms   symptoms   concurrently   met   criteria   for   a   major  
in   the   absence   of   a   major   mood   episode   [depressive   depressive   episode   and   Criterion   A   for  
or  manic]),     schizophrenia,   and   during   this   same   period   of  
§ it   is   important   to   know   when   the   affective   illness,   auditory   hallucinations   and   delusions  
episode  ends  and  the  psychosis  continues.     were   present   both   before   and   after   the   depressive  
o To   meet   Criterion   C,   the   length   of   all   mood   phase.    
episodes  must  be  combined  and  compared  with  the    
total  length  of  the  illness.     o The  total  period  of  illness  lasted  for  about  6  
If  the  mood  component  is  present  for  the  majority  (>50%)  of  the   months,  with:  
total  illness,  then  that  criterion  is  met   § psychotic   symptoms   alone   present   during   the  
  initial  2  months  
  § both   depressive   and   psychotic   symptoms   present  
  during  the  next  3  months  
  § psychotic  symptoms  alone  present  during  the  last  
month.    
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 o In   this   instance,   duration   of   depressive   Delusional  Disorder  
episode   was   not   brief   relative   to   the   total   duration   of   Diagnostic  Criteria  (DSM  V)  
the  psychotic  disturbance   A.  The  presence  of  one  (or  more)  delusions  with  a  duration  of  
§ thus   the   presentation   qualifies   for   a   diagnosis   of   one  month  or  longer    
schizoaffective  disorder.    
 
B.  .  Criterion  A  for  schizophrenia  has  never  been  met.  Note:  
• The   expression   of   psychotic   symptoms   across   the   lifespan   is  
Hallucinations,  if  present,  are  not  prominent  and  are  related  
variable.  
to  the  delusional  theme  (e.g.,  the  sensation  of  being  infested  
 
with  insects  associated  with  delusions  of  infestation)    
• Depressive  or  manic  symptoms  can  occur  before  the  onset  of  
psychosis,  during:   • Okay  recall,  Criterion  A  for  schizophrenia  is  At  least  2  
o acute  psychotic  episodes   or  more  of  the  following,  with  AT  LEAST  1  from  A  B  
o residual  periods   C  and  the  other  one  from  any,  for  at  least  1  month:  
o or  after  cessation  of  psychosis.     ◦ Delusions  
  ◦ Hallucinations  
• Schizoaffective  disorder,  bipolar  type,  may  be  more  common   ◦ Disorganized  Speech  
in  young  adults  
◦ Grossly  disorganized  behavior  or  catatonic  
• Whereas   schizoaffective   disorder,   depressive   type,   may   be  
behavior  
more  common  in  older  adults  
◦ Negative  symptoms    
Differential  Diagnosis    
• To  rule  out  organic  causes  for  the  symptoms  perform  a   C.  Apart  from  the  impact  of  the  delusion(s)  or  its  ramifications,  
complete  medical  workup   functioning  is  not  markedly  impaired,  and  behavior  is  not  
• A   history   of   substance   use   (with   or   without   positive   obviously  bizarre  or  odd.    
results   on   a   toxicology   screening   test)   may   indicate   a   • According  to  Doc  Los  Banos,  what  constitutes  a  delusion  
substance-­‐induced  disorder.   being  bizarre  or  odd?  
• Preexisting  medical  conditions,  their  treatment,  or  both   ◦ Being  out  of  place  (Aliens  sa  philippines,  and  
can  cause  psychotic  and  mood  disorders.     aswang  sa  states)  
• Any   suspicion   of   a   neurological   abnormality   warrants    
consideration   of   a   brain   scan   to   rule   out   anatomical   D.  If  manic  or  major  depressive  episodes  have  occurred,  these  
pathology   and   an   electroencephalogram   to   determine   any   have  been  brief  relative  to  the  duration  of  the  delusional  periods.  
possible  seizure  disorders  (e.g.,  temporal  lobe  epilepsy).    
•  Psychotic   disorder   caused   by   seizure   disorder   is   more   E.  The  disturbance  is  not  attributable  to  the  physiological  effects  
common  than  that  seen  in  the  general  population.     of  a  substance  or  another  medical  condition  and  is  not  better  
o It   tends   to   be   characterized   by   paranoia,   explained  by  another  mental  disorder,  such  as  body  dysmorphic  
hallucinations,  and  ideas  of  reference.     disorder  or  obsessive-­‐compulsive  disorder.    
• Patients   with   epilepsy   with   psychosis   are   believed   to  
 
have   a   better   level   of   function   than   patients   with  
schizophrenic  spectrum  disorders.   Specify  whether:    
o  Better   control   of   the   seizures   can   reduce   the   • Erotomanic  Type  
psychosis.   ◦ This  subtype  applies  when  the  central  theme  of  the  
Table  1.  Summary  of  other  disoders  (First  3)   delusion  is  that  another  person  is  in  love  with  the  
Other  Forms     Duration   Criteria   individual.    
Schizophreniform   1  to  6  months   Criteria  A,  D,  E   • Grandiose  Type  
Two  or  more  of  the  ff:     ◦ This  subtype  applies  when  the  central  theme  of  the  
1. Delusions   delusion  is  the  conviction  of  having  some  great  (but  
2. Hallucinations   unrecognized)  talent  or  insight  or  having  made  
3. Disorganized   some  important  discovery.    
speech   • Jealous  Type  
4. Grossly  
◦ This  subtype  applies  when  the  central  theme  of  the  
disorganized   or  
individual’s  delusion  is  that  his  or  her  spouse  or  
catatonic  
lover  is  unfaithful.    
behavior  
5. Negative   • Persecutory  Type  
symptoms   ◦ This  subtype  applies  when  the  central  theme  of  the  
Brief   Psychotic   1   day   to   1   One   symptom   of   the   delusion  involves  the  individual’s  belief  that  he  or  
Disorder   month     first  four  criteria  above   she  is  being  conspired  against,  cheated,  spied  on,  
Schizoaffective     Delusions   with   mood   followed,  poisoned  or  drugged,  maliciously  
(equal  prominence)   maligned,  harassed,  or  obstructed  in  the  pursuit  of  
Two   weeks   of   pure   long-­‐term  goals.    
psychosis   ◦  

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 • Somatic  Type   ranging  from  0  (not  present)  to  4  (present  and  
◦ This  subtype  applies  when  the  central  theme  of  the   severe).  (See  Clinician-­‐Rated  Dimensions  of  Psychosis  
delusion  involves  bodily  functions  or  sensations.     Symptom  Severity  in  the  chapter  “Assessment  
Measures.”)    
• Mixed  Type  
 
◦ This  subtype  applies  when  no  one  delusional  
Note:  Diagnosis  of  delusional  disorder  can  be  made  without  using  
theme  predominates.    
this  severity  specifier.    
• Unspecified  Type  
 
◦ This  subtype  applies  when  the  dominant  delusional   Subtypes  
belief  cannot  be  clearly  determined  or  is  not  
1. Erotomaniac  Type  
described  in  the  specific  types  (e.g.,  referential  
delusions  without  a  prominent  persecutory  or   • the  central  theme  of  delusion  is  that  another  person  is  
grandiose  component).     in  love  with  the  individual  
Specify  if  with:   • usually  of  higher  status  but  can  be  a  complete  stranger    
• Bizarre  Content   2. Grandiose  Type  
◦ Delusions  are  deemed  bizarre  if  they  are  clearly   • conviction  of  having  some  great  talent  or  insight  or  
implausible,  not  understandable,  and  not  derived   of  having  made  some  important  discovery    
from  ordinary  life  experiences  (e.g.,  an  individual’s   3. Jealous  Type  
belief  that  a  stranger  has  removed  his  or  her   • delusion  of  an  unfaithful  partner  
internal  organs  and  replaced  them  with  someone   • belief  is  arrived  at  whit  no  due  cause  and  is  based  
else’s  organs  without  leaving  any  wounds  or  scars).   on  incorrect  inferences  supported  by  small  bits  of  
  “evidence”    
Specify  if:   4. Persecutory  Type  
The  following  course  specifiers  are  only  to  be  used  after  a  1  -­‐  year   • belief  of  being  conspired  against,  cheated,  spied,  
duration  of  the  disorder:     followed,  poisoned,  maliciously  maligned,  harassed  
  or  obstructed  in  the  pursuit  of  long  term  goals.    
• First  episode,  currently  in  acute  episode     5. Somatic  Type  
◦ First  manifestation  of  the  disorder  meeting  the   • involves  bodily  functions  or  sensations  •  ie.  
defining  diagnostic  symptom  and  time  criteria.  An   individual  emits  a  foul  odor,  infestation  of  insects  
acute  episode  is  a  time  period  in  which  the   on  the  skin,  internal  parasite  or  other  parts  of  the  
symptom  criteria  are  fulfilled.   body  are  not  functioning    
• First  episode,  currently  in  partial  remission   Diagnostic  Features:  
◦ Partial  remission  is  a  time  period  during  which  an   • Essential  feature  of  delusional  disorder  is  the  presence  
improvement  after  a  previous  episode  is   of  one  or  more  delusions  that  persist  for  at  least  1  
maintained  and  in  which  the  defining  criteria  of  the   month  (Criterion  A).  
disorder  are  only  partially  fulfilled.     • Diagnosis  of  delusional  disorder  is  not  given  if  the  
• First  episode,  currently  in  full  remission   individual  has  ever  had  a  symptom  presentation  that  
met  Criterion  A  for  schizophrenia  (Criterion  B).  
◦ Full  remission  is  a  period  of  time  after  a  previous  
episode  during  which  no  disorder-­‐specific   • Apart  from  the  direct  impact  of  the  delusions,  
symptoms  are  present.     impairments  in  psychosocial  functioning  may  be  more  
circumscribed  than  those  seen  in  other  psychotic  
• Multiple  episodes,  currently  in  acute  episode  
disorders  such  as  schizophrenia,  and  behavior  is  not  
• Multiple  episodes,  currently  in  partial  remission   obviously  bizarre  or  odd  (Criterion  C).  
• Multiple  episodes,  currently  in  full  remission   • If  mood  episodes  occur  concurrently  with  the  delusions,  
• Continuous   the  total  duration  of  these  mood  episodes  is  brief  
◦ Symptoms  fulfilling  the  diagnostic  symptom   relative  to  the  total  duration  of  the  delusional  periods  
criteria  of  the  disorder  are  remaining  for  the   (Criterion  D).  
majority  of  the  illness  course,  with  subthreshold   • The  delusions  are  not  attributable  to  the  physiological  
symptom  periods  being  very  brief  relative  to  the   effects  of  a  substance  (e.g.,  cocaine)  or  another  medical  
overall  course.     condition  (e.g.,  Alzheimer's  disease)  and  are  not  better  
• Unspecified     explained  by  another  mental  disorder,  such  as  body  
    dysmorphic  disorder  or  obsessive-­‐compulsive  disorder  
Specify  current  severity:     (Criterion  E).    
• Severity  is  rated  by  a  quantitative  assessment  of  the    
primary  symptoms  of  psychosis,  including  delusions,   Associated  Features  that  can  support  diagnosis:  
hallucinations,  disorganized  speech,  abnormal   • Social,  marital,  or  work  problems  can  result  from  the  
psychomotor  behavior,  and  negative  symptoms.  Each  of   delusional  beliefs  of  delusional  disorder.  •  Individuals  
these  symptoms  may  be  rated  for  its  current  severity   with  delusional  disorder  may  be  able  to  factually  
(most  severe  in  the  last  7  days)  on  a  5-­‐point  scale   describe  that  others  view  their  beliefs  as  irrational  but  

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 are  unable  to  accept  this  themselves  (i.e.,  there  may  be   • A  substance/  medication-­‐induced  psychotic  
"factual  insight"  but  no  true  insight).   disorder  crosssectionally  may  be  identical  in  
• Many  individuals  develop  irritable  or  dysphoric  mood,   symptomatology  to  delusional  disorder  but  can  be  
which  can  usually  be  understood  as  a  reaction  to  their   distinguished  by  the  chronological  relationship  of  
delusional  beliefs.     substance  use  to  the  onset  and  remission  of  the  
• Anger  and  violent  behavior  can  occur  with  persecutory,   delusional  beliefs.    
jealous,  and  erotomanic  types.  The  individual  may   3. Schizophrenia  and  schizophreniform  disorder    
engage  in  litigious  or  antagonistic  behavior  (e.g.,   • Delusional  disorder  can  be  distinguished  from  
sending  hundreds  of  letters  of  protest  to  the   schizophrenia  and  schizophreniform  disorder  by  
government).     the  absence  of  the  other  characteristic  symptoms  
• Legal  difficulties  can  occur,  particularly  in  jealous  and   of  the  active  phase  of  schizophrenia.    
erotomanie  types.   4. Depressive  and  bipolar  disorders  and  
  schizoafferctive  disorder    
Development  and  Course   • May  be  distinguished  from  delusional  disorder  by  
the  temporal  relationship  between  mood  
• On  average,  global  function  is  generally  better  than  that  
disturbance  &  delusions  &  by  the  severity  of  the  
observed  in  schizophrenia.  
mood  symptoms.    
• Although  the  diagnosis  is  generally  stable,  a  proportion  
• If  delusions  occur  exclusively  during  mood  
of  individuals  go  on  to  develop  schizophrenia.    
episodes,  the  diagnosis  is  depressive  or  bipolar  
• Although  it  can  occur  in  younger  age  groups,  the   disorder  with  psychotic  features.  
condition  may  be  more  prevalent  in  older  individuals.    
• Mood  symptoms  that  meet  full  criteria  for  a  mood  
Culture  Related  Diagnostic  Issues   episode  can  be  superimposed  on  delusional  
• Cultural  and  religious  background  must  be  taken  into   disorder.  
account  in  evaluating  the  possible  presence  of   • Delusional  disorder  can  be  diagnosed  only  if  the  
delusional  disorder  because  the  content  of  delusions   total  duration  of  all  mood  episodes  remains  brief  
also  varies  across  cultural  contexts.     relative  to  the  total  duration  of  the  delusional  
  disturbance.    
Functional  Consequence  of  Delusional  Disorder    
• Functional  impairment  is  usually  more  circumscribed   SHARED  PSYCHOTIC  DISORDER  (Folie  a  Deux)  
than  that  seen  with  other  psychotic  disorders.     Diagnostic  Criteria  
• Although  in  some  cases,  the  impairment  may  be   • A  delusion  develops  in  an  individual  in  the  context  of  a  
substantial  and  include  poor  occupational  functioning   close   relationship   with   another   person(s),   who   has   an  
and  social  isolation.     already  established  delusion.  
• A  common  characteristic  of  individuals  with  delusional   • The  delusion  is  similar  in  content  to  that  of  the  person  
disorder  is  the  apparent  normality  of  their  behaviour   who  already  has  the  established  delusion.  
and  appearance  when  their  delusional  ideas  are  not   • The  disturbance  is  not  better  accounted  for  by  another  
being  discussed  or  acted  on.     Psychotic   Disorder   (e.g.,   Schizophrenia)   or   a   Mood  
Differential  Diagnosis   Disorder  With  Psychotic  Features  and  is  not  due  to  the  
1. Obsessive-­‐  compulsive  and  related  disorders     direct  physiological  effects  of  a  substance  (e.g.,  a  drug  of  
abuse,  a  medication)  or  a  general  medical  condition.    
• If  an  individual  with  OCD  is  completely  convinced  
 
that  his  or  her  OCD  beliefs  are  true,  then  the  
diagnosis  of  obsessivecompulsive  disorder,  with   Note:  Again,  from  DSM  IV  (it  exists  in  DSM-­‐V  only  in  the  section  
absent  insight/delusional  beliefs  specifier,  should   on   other   specified   schizophrenic   spectrum   and   other   psychotic  
be  given  rather  than  a  diagnosis  of  delusional   disorders,  as  “delusional  symptoms  in  partner  of  individual  with  
delusional  disorder”.    
disorder.  
 
• Similarly,  if  an  individual  with  body  dysmorphic  
PSYCHOTIC  DISORDER  DUE  TO  ANOTHER  MEDICAL  
disorder  (BDD)  is  completely  convinced  that  his  
CONDITION  
or  her  BDD  beliefs  are  true,  then  the  diagnosis  of  
body  dysmorphic  disorder,  with  absent   Diagnostic  Criteria  
insight/delusional  beliefs  specifier,  should  be  given   • Prominent  hallucinations  or  delusions.  
rather  than  a  diagnosis  of  delusional  disorder.     • There   is   evidence   from   the   history,   physical  
2. Delirium,  major  neurocognitive  disorder,  psychotic   examination,  or  laboratory  findings  that  thedisturbance  
disorder  due  to  another  medical  condition,   is  the  direct  pathophysiological  consequence  of  another  
substance/  medication  induced  disorder     medical  condition  
• Individuals  with  these  disorders  may  present  with   • The   disturbance   is   not   better   explained   by   another  
mental  disorder.  
symptoms  that  suggest  delusional  disorder.    
• The   disturbance   does   not   occur   exclusively   during   the  
• For  example,  simple  persecutory  delusions  in  the  
course  of  a  delirium.    
context  of  major  neurocognitive  disorder  would  be  
diagnosed  as  major  neurocognitive  disorder,  with  
behavioral  disturbance.  
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 • The   disturbance   causes   clinically   significant   distress   or   • In   determining   whether   the   psychotic   disturbance   is  
impairment   in   social,   occupational,   or   other   important   attributable  to  another  medical  condition,  the  presence  
areas  of  functioning.     of   a   medical   condition   must   be   identified   and  
  considered   to   be   the   etiology   of   the   psychosis  
Specify  whether:   through  a  physiological  mechanism.  
• With   delusions:   If   delusions   are   the   predominant   • Although   there   are   no   infallible   guidelines   for  
symptom.   determining   whether   the   relationship   between   the  
• With   hallucinations:   If   hallucinations   are   the   psychotic   disturbance   and   the   medical   condition   is  
predominant  symptom.     etiological,   several   considerations   provide   some  
  guidance:  
Specify  current  severity:   ◦ Presence   of   a   temporal   association   between   the  
• Severity   is   rated   by   a   quantitative   assessment   of   the   onset,   exacerbation,   or   remission   of   the   medical  
primary   symptoms   of   psychosis,   including   delusions,   condition  and  that  of  the  psychotic  disturbance.  
hallucinations,   abnormal   psychomotor   behavior,   and   ◦ Presence   of   features   that   are   atypical   for   a  
negative   symptoms.   Each   of   these   symptoms   may   be   psychotic   disorder   (e.g.,   atypical   age   at   onset   or  
rated  for  its  current  severity  (most  severe  in  the  last   presence  of  visual  or  olfactory  hallucinations).  
7   days)   on   a   5-­‐point   scale   ranging   from   0   (not   ◦ Disturbance   must   also   be   distinguished   from   a  
present)  to  4  (present  and  severe).   substance/medication-­‐induced   psychotic   disorder  
• Note:   Diagnosis   of   psychotic   disorder   due   to   another   or   another   mental   disorder   (e.g.,   an   adjustment  
medical   condition   can   be   made   without   using   this   disorder).    
severity  specifier.      
  Associated  Features  Supporting  Diagnosis  
Specifiers   • The  temporal  association  of  the  onset  or  exacerbation  of  
• In   addition   to   the   symptom   domain   areas   identified   in   the   medical   condition   offers   the   greatest   diagnostic  
the   diagnostic   criteria,   the   assessment   of   cognition,   certainty   that   the   delusions   or   hallucinations   are  
depression,  and  mania  symptom  domains  is  vital  for  making   attributable  to  a  medical  condition.  
critically   important   distinctions   between   the   various   • Additional  factors  may   include  concomitant  treatments  
schizophrenia  spectrum  and  other  psychotic  disorders.     for   the   underlying   medical   condition   that   confer   a   risk  
Diagnostic  Features   for   psychosis   independently,   such   as   steroid   treatment  
• The   essential   features   of   psychotic   disorder   due   to   for  autoimmune  disorders.    
another  medical  condition:   Prevalence  
◦ Prominent   delusions   or   hallucinations   that   are   • Lifetime  prevalence:  0.21%  to  0.54%.  
judged   to   be   attributable   to   the   physiological   ◦ individuals   >65   y/o   have   a   significantly   greater  
effects   of   another   medical   condition   and   are   not   prevalence   of   0.74%   compared   with   those   in  
better  explained  by  another  mental  disorder   younger  age  groups.  
▪ (e.g.,   the   symptoms   are   not   a   psychologically   ◦ Higher  prevalence  of  the  disorder  in  females  
mediated   response   to   a   severe   medical   • Rates  of  psychosis  also  vary  according  to  the  underlying  
condition,   in   which   case   a   diagnosis   of   brief   medical  condition  
psychotic   disorder,   with   marked   stressor,   • Conditions   most   commonly   associated   with   psychosis  
would  be  appropriate).   include:  
• Hallucinations   can   occur   in   any   sensory   modality   (i.e.,   ◦ untreated   endocrine   and   metabolic   disorders,  
visual,   olfactory,   gustatory,   tactile,   or   auditory),   but   autoimmune   disorders   (e.g.,   SLE,   N-­‐methyl-­‐D-­‐
certain   etiological   factors   are   likely   to   evoke   specific   aspartate   (NMDA)   receptor   autoimmune  
hallucinatory  phenomena.   encephalitis)  
◦ Olfactory   hallucinations   are   suggestive   of   ◦ temporal  lobe  epilepsy  
temporal  lobe  epilepsy.  
▪ Psychosis   due   to   epilepsy   has   been   further  
◦ Hallucinations  may  vary  from  simple  and  unformed   differentiated   into   ictal,   postictal,   and  
to   highly   complex   and   organized,   depending   on   interictal   psychosis.   The   most   common   of  
etiological  and  environmental  factors.   these   is   postictal   psychosis,   (2%-­‐7.8%   of  
◦ Psychotic   disorder   due   to   another   medical   epilepsy  patients.)    
condition  is  generally  NOT  DIAGNOSED  if:    
▪ the  individual  maintains  reality  testing  for  the   Development  and  Course  
hallucinations  and  appreciates  that  they  result   • Psychotic   disorder   due   to   another   medical   condition  
from  the  medical  condition.   may   be   a   single   transient   state   or   it   may   be   recurrent,  
• Delusions   may   have   a   variety   of   themes,   including   cycling   with   exacerbations   and   remissions   of   the  
somatic,   grandiose,   religious,   and,   most   commonly,   underlying  medical  condition.  
persecutory.   • Although   treatment   of   the   underlying   medical   condition  
• On  the  whole,  however,  associations  between  delusions   often  results  in  a  resolution  of  the  psychosis,  this  is  not  
and   particular   medical   conditions   appear   to   be   less   always   the   case,   and   psychotic   symptoms   may   persist  
specific  than  is  the  case  for  hallucinations.   long   after   the   medical   event   (e.g.,   psychotic   disorder  
due  to  focal  brain  injury).  
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  Risk  and  Prognostic  Factors   • More   characteristic   of   schizophrenia   than   of   psychotic  
• Course  modifiers.   disorder  due  to  a  medical  condition.    
◦ Identification   and   treatment   of   the   underlying    
medical   condition   has   the   greatest   impact   on   Comorbidity  
course,   although   preexisting   CNS   injury   may   confer   • Psychotic  disorder  due  to  another  medical  condition  in  
a  worse  course  outcome.     those   >80   y/o   is   associated   with   concurrent   major  
  neurocognitive  disorder  (dementia).    
Diagnostic  Markers   Table  2.  Summary  Table  of  Disorders  
• Diagnosis  of  psychotic  disorder  due  to  another  medical   Other  Forms     Duration   Criteria  
condition   depends   on   the   clinical   condition   of   each   Delusional   One   month   or   1  or  more  delusions  
individual,   and   the   diagnostic   tests   will   vary   according   Disorder   longer   Crit   A   has   never   been  
to  that  condition.     met:   if   hallucinations  
  are   present,   make   sure  
Functional  Consequences   they   are   related   to   the  
• Functional   disability   is   typically   severe   in   the   context   of   delusional  theme  
psychotic  disorder  due  to  another  medical  condition  but   Delusions   are   NOT  
will   vary   considerably   by   the   type   of   condition   and   bizzare  or  odd  
likely   improve   with   successful   resolution   of   the   Shared   Psychotic   N/A   Two   people   sharing   the  
condition.     Disorder   same  
  hallucination/delusion  
Differential  Diagnosis   Close   relationship  
1. Delirium   between   the   two  
• Hallucinations   and   delusions   commonly   occur   in   the   persons  
context  of  a  delirium;   Due   to   another   N/A   Prominent  
• A   separate   diagnosis   of   psychotic   disorder   due   to   medical  condition   Hallucinations   and  
another   medical   condition   is   not   given   if   the   delusions  
disturbance   occurs   exclusively   during   the   course   of   a   Can   be   explained   by  
delirium.   pathophysiology   of   the  
• Delusions   in   the   context   of   a   major   or   mild   condition  
neurocognitive   disorder   would   be   diagnosed   as   major   Substance   Abuse   N/A   Presence   of   one   or   both  
or   mild   neurocognitive   disorder,   with   behavioural   related   of:   (1)   delusions   ,   (2)  
disturbance.     hallucinations  
2. Substance/Medication  Induced   Symptoms   in   Crit.   A  
• Considered   if   there   is   evidence   of   recent   or   prolonged   developed   after   intake  
substance  use  (including  medications  with  psychoactive   or  substances  
effects),  withdrawal  from  a  substance,  or  exposure  to  a   Involved   substance  
toxin  (e.g.,  LSD  [lysergic  acid  diethylamide]  intoxication   produces   effects   (Meth  
alcohol  withdrawal)   =  Schiz)  
• Symptoms   that   occur   during   or   shortly   after   (i.e.,   within    
4   weeks)   of   substance   intoxication   or   withdrawal   or   SUBSTANCE  /  MEDICATION  INDUCED  PSYCHOTIC  DISORDER  
after   medication   use   may   be   especially   indicative   of   a  
Diagnostic  Criteria  
substanceinduced  psychotic  disorder,  depending  on  the  
character,  duration,  or  amount  of  the  substance  used.    
A. Presence  of  one  or  both  of  the  following  symptoms:  
• If   the   clinician   has   ascertained   that   the   disturbance   is  
1. Delusions.  
due  to  both  a  medical  condition  and  substance  use,  both  
2. Hallucinations.  
diagnoses   (i.e.,   psychotic   disorder   due   to   another  
B. There   is   evidence   from   the   history,   physical   Examination,   or  
medical   condition   and   substance/medication-­‐induced  
laboratory  findings  of  both  (1)  and  (2):  
psychotic  disorder)  can  be  given.    
1. The   symptoms   in   Criterion   A   developed   during   or   soon  
 
after   substance   intoxication   or   withdrawal   or   after  
3. Psychotic  Disorder  
exposure  to  a  medication.  
• In   psychotic   disorders   and   in   depressive   or   bipolar  
2. The   involved   substance/medication   is   capable   of  
disorders,  with  psychotic  features,  no  specific  and  direct  
producing  the  symptoms  in  Criterion  A.  
causative   physiological   mechanisms   associated   with   a  
C. The   disturbance   is   not   better   explained   by   a   psychotic  
medical  condition  can  be  demonstrated.  
disorder   that   is   not   substance   /   medication-­‐induced.   Such  
• Late   age   at   onset   and   the   absence   of   a   personal   or   evidence  of  an  independent  psychotic  disorder  could  include  
family   history   of   schizophrenia   or   delusional   disorder  
the  following:  
suggest  the  need  for  a  thorough  assessment  to  rule  out  
• The   symptoms   preceded   the   onset   of   the  
the   diagnosis   of   psychotic   disorder   due   to   another  
substance/medication  use  
medical  condition.  
• The   symptoms   persist   for   a   substantial   period   of   time  
• Auditory   hallucinations   that   involve   voices   speaking  
(e.g.,   about   1   month)   after   the   cessation   of   acute  
complex  sentences  
withdrawal  or  severe  intoxication  

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 • There   is   other   evidence   of   an   independent   non-­‐ ◦ substance  withdrawal  
substance/medication-­‐induced  psychotic  disorder     Arise   during   or   soon   after   exposure   to   a   medication  
◦ e.g.,   a   history   of   recurrent   non-­‐ or   after   substance   intoxication   or   withdrawal   but   can  
substance/medication-­‐related  episodes   persist  for  weeks  
D. The   disturbance   does   not   occur   exclusively   during   the   • whereas   primary   psychotic   disorders   may   precede   the  
course  of  a  delirium.   onset   of   substance/medication   use   or   may   occur   during  
E. The   disturbance   causes   clinically   significant   distress   or   times  of  sustained  abstinence  
impairment   in   social,   occupational,   or   other   important   areas   • Once   initiated,   psychotic   symptoms   may   continue   as  
of  functioning.   long  as  substance/medication  use  continues.    
  Another   consideration   is   the   presence   of   features   that  
Specify  if:   are  atypical  of  a  primary  psychotic  disorder    
With  onset  during  intoxication:   • e.g.,  atypical  age  at  onset  or  course  
◦ If   the   criteria   are   met   for   intoxication   with   the   ◦ example:  the  appearance  of  delusions  de  novo  in  a  
substance   and   the   symptoms   develop   during   person   older   than   35   years   without   a   known  
intoxication.   history   of   a   primary   psychotic   disorder   should  
With  onset  during  withdrawal:     suggest   possibility   of   a   substance/   medication-­‐
◦ If   the   criteria   are   met   for   withdrawal   from   the   induced  psychotic  disorder.    
substance   and   the   symptoms   develop   during,   or   Even   a   prior   history   of   a   primary   psychotic   disorder  
shortly  after,  withdrawal.   does   not   rule   out   the   possibility   of   a   substance/  
  medication-­‐induced  psychotic  disorder.  
Specify  current  severity:   In   contrast,   factors   that   suggest   that   the   psychotic  
Severity   is   rated   by   a   quantitative   assessment   of   the   symptoms   are   better   accounted   for   by   a   primary  
primary  symptoms  of  psychosis,  including:   psychotic   disorder   include   persistence   of   psychotic  
• Delusions   symptoms  for  a  substantial  period  of  time  (i.e.,  a  month  
• Hallucinations   or   more)   after   the   end   of   substance   intoxication   or  
• Abnormal  psychomotor  behaviour   acute   substance   withdrawal   or   after   cessation   of  
• Negative  symptoms   medication  use;  or  a  history  of  prior  recurrent  primary  
Each   of   these   symptoms   may   be   rated   for   its   current   psychotic  disorders.  
severity   (most   severe   in   the   last   7   days)   on   a   5-­‐point   Other   causes   of   psychotic   symptoms   must   be  
scale   ranging   from   0   (not   present)   to   4   (present   and   considered   even   in   an   individual   with   substance  
severe).     intoxication   or   withdrawal,   because   substance   use  
  problems   are   not   uncommon   among   individuals   with  
Note:   Diagnosis   of   substance/medication-­‐induced   psychotic   non-­‐substance/medication-­‐induced  psychotic  d/o.  
disorder  can  be  made  without  using  this  severity  specifier.   In   addition   to   the   five   symptom   domain   areas   identified  
  in   the   diagnostic   criteria,   to   make   critically   important  
  decisions  between  various  schizophrenia  spectrum  and  
Diagnostic  Features   other  psychotic  disorders,  it  is  vital  to  assess:  
The  essential  features:   • Cognition  
• Prominent   delusions   and/or   hallucinations   (Criterion   • Depression  
A)   • Mania  symptom  domains  
1. that   are   judged   to   be   due   to   the   physiological    
effects  of  a  substance/medication   Associated  Features  Supporting  Diagnosis  
1. i.e.   a   drug   of   abuse,   a   medication,   or   a   Psychotic  disorders  can  occur  in  association  with  intoxication  
toxin  exposure  (Criterion  B)   with  the  following  classes  of  substances:  
2. hallucinations   that   the   individual   realizes   are   • Alcohol  
substance/medication-­‐induced   are   not   • Cannabis  
included   here   and   instead   would   be   diagnosed   • Hallucinogens[Phencyclidine  &related  substances]  
as   substance   intoxication   or   substance   • Inhalants  
withdrawal   with   the   accompanying   specifier   • Sedatives  
"with  perceptual  disturbances"  –  applies  to:   • Hypnotics  
1. alcohol  withdrawal   • Anxiolytics  
2. cannabis  intoxication   • Stimulants    [Cocaine]  
3. sedative,   hypnotic,   or   anxiolytic   • Other  (or  unknown)  substances  
withdrawal   Psychotic  disorders  can  occur  in  association  with  
4. stimulant  intoxication   withdrawalfrom  the  following  classes  of  substances:  
Distinguished   from   a   primary   psychotic   disorder   by   • Alcohol  
considering  the:  onset,  course  and  other  factors.   • Sedatives  
For   drugs   of   abuse,   there   must   be   evidence   from   the   • Hypnotics  
history,  PE,  or  laboratory  findings  of:   • Anxiolytics;  
◦ substance  use   • Other  (or  unknown)  substances  
◦ substance  intoxication  

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Some  medications  reported  to  evoke  psychotic   May   at   times   persist   when   the   offending   agent   is  
symptomsinclude:   removed  
• anesthetics  and  analgesics   • such   that   it   may   be   difficult   initially   to   distinguish   it  
• Anticholinergic  agents   from  an  independent  psychotic  disorder  
• Anticonvulsants   Agents   such   as   amphetamines,   phencyclidine,   and  
• Antihistamines   cocaine   have   been   reported   to   evoke   temporary  
• Antihypertensive  and  cardiovascular  medications   psychotic   states   that   can   sometimes   persist   for   weeks  
• Antimicrobial  medications   or   longer   despite   removal   of   the   agent   and   treatment  
• Antiparkinsonian  medications   with  neuroleptic  medication.  
• Chemotherapeutic  agents   In   later   life,   polypharmacy   for   medical   conditions   and  
exposure   to   medications   for   parkinsonism,  
◦ Cyclosporine  &  Procarbazine  
cardiovascular   disease,   and   other   medical   disorders  
• Corticosteroids  
may  be  associated  with  a  greater  likelihood  of  psychosis  
• Gastrointestinal  medications  
induced   by   prescription   medications   as   opposed   to  
• Muscle  relaxants   substances  of  abuse  
• Nonsteroidal  anti-­‐inflammatory  medications  (NSAIDs)    
• Other  over-­‐the-­‐counter  medications     Diagnostic  Markers  
◦ Phenylephrine   With   substances   for   which   relevant   blood   levels   are  
◦ Pseudoephedrine     available:  
• Antidepressant  medication   • Blood  alcohol  level  
• Disulfiram   • Other  quantifiable  blood  levels  (e.g.  Digoxin)  
Toxins  reported  to  induce  psychotic  symptoms  include:   • the   presence   of   a   level   consistent   with   toxicity   may  
• Anticholinesterase   increase  diagnostic  certainty  
• Organophosphate  insecticides   Functional  Consequences  
• Sarin  and  other  nerve  gases   Typically  severely  disabling    
• Carbon  monoxide   • observed  most  frequently  in  emergency  rooms  
• Carbon  dioxide   • as   individuals   are   often   brought   to   the   acute-­‐care  
• Volatile  substances     setting  when  it  occurs    
Prevalence   • However,   the   disability   is   typically   self-­‐limited   and   resolves  
Between   7%   and   25%   of   individuals   presenting   with   a   upon  removal  of  the  offending  agent  
first  episode  of  psychosis  in  different  settings:    
• have  substance/medication-­‐induced  psychotic    
disorder   Differential  Diagnosis  
 
substance  intoxication/withdrawal  
Development  and  Course  
The   initiation   of   the   disorder   may   vary   considerably   • Individuals   intoxicated   with   stimulants,   cannabis,   the  
with  the  substance.     opioid   meperidine,   or   phencyclidine,   or   those  
For   example,   smoking   a   high   dose   of   cocaine   may   produce   withdrawing  from  alcohol  or  sedatives  may  experience  
psychosis   within   minutes,   whereas   days   or   weeks   of   high-­‐dose   altered   perceptions   that   they   recognize   as   drug  
alcohol  or  sedative  use  may  be  required  to  produce  psychosis.     effects.    
Alcohol-­‐induced  psychotic  disorder,  with  hallucinations   • If   reality   testing   for   these   experiences   remains   intact  
Usually   occurs   only   after   prolonged,   heavy   ingestion   of   alcohol   in   (i.e.,   the   individual   recognizes   that   the   perception   is  
individuals  who  have  moderate  to  severe  alcohol  use  disorder   substance   induced   and   neither   believes   in   nor   acts   on  
Hallucinations  are  generally  auditory  in  nature.   it):  
Psychotic   disorders   induced   by   amphetamine   and   • Diagnosis   is   not   substance/medication-­‐induced  
cocaine  share  similar  clinical  features.   psychotic  disorder  
◦ Persecutory   delusions   may   rapidly   develop   • Instead;   substance   intoxication   or   substance  
shortly   after   use   of   amphetamine   or   a   similarly   withdrawal,  with  perceptual  disturbances  
acting  sympathomimetic.     • e.g.,  cocaine  intoxication,  with  perceptual  disturbances  
The   hallucination   of   bugs   or   vermin   crawling   in   or    
under  the  skin  (formication)  can  lead  to  scratching  and   HALLUCINOGEN  PERSISTING  PERCEPTION  DISORDER  
extensive  skin  excoriations.   • Flashback"   hallucinations   occurring     long   after   the   use  
Cannabis-­‐induced   psychotic   disorder   may   develop   of  hallucinogens  has  stopped    
shortly   after   high-­‐dose   cannabis   use   and   usually   • If   substance/medication-­‐induced   psychotic   symptoms  
involves:   occur   exclusively   during   the   course   of   a   delirium,   as   in  
• persecutory  delusions   severe  forms  of  alcohol  withdrawal,  
• marked  anxiety   • the   psychotic   symptoms   are   considered   to   be   an  
• emotional  lability   associated  feature  of  the  delirium  and  are  not  diagnosed  
• depersonalization   separately  
The   disorder   usually   remits   within   a   day   but   in   some   • Delusions   in   the   context   of   a   major   or   mild  
cases  may  persist  for  a  few  days.   neurocognitive  disorder    

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 ◦ Diagnosis   is   major   or   mild   neurocognitive   ◦ Excessive  And  Peculiar  Motor  Activity  
disorder,  with  behavioral  disturbance   ▪ complex  (ex.  Stereotypy)  
  ▪ simple  (agitation)  
PRIMARY  PSYCHOTIC  DISORDER   ▪ may  include  echolalia  and  echopraxia  
• Substance/medication-­‐induced   psychotic   disorder   is   Clinical  presentation  of  catatonia  can  be  puzzling,  as  the  
distinguished   from   a   primary   psychotic   disorder   by   the   fact   psychomotor   disturbance   may   range   from   marked  
that   a   substance   is   judged   to   be   etiologically   related   to   the   unresponsiveness  to  marked  agitation  
symptoms   In   extreme   cases,   the   same   individual   may   wax   and  
  wane  between  decreased  &  excessive  motor  activity  
PSYCHOTIC  DISORER  DUE  TO  ANOTHER  MEDICAL   During   severe   stages   of   catatonia,   the   individual   may  
CONDITION   need  careful  supervision  to  avoid  self-­‐harm  or  harming  
• Substance/medication-­‐induced   psychotic   disorder   due   others;   there   are   potential   risks   from   malnutrition,  
to   a   prescribed   treatment   for   a   mental   or   medical   exhaustion,  hyperpyrexia  and  self-­‐inflicted  injury.  
condition   must   have   its   onset   while   the   individual   is    
receiving   the   medication   (or   during   withdrawal,   if   Catatonia  Assoicated  with  Another  Mental  Diorder  (DSM  V  
there   is   a   withdrawal   syndrome   associated   with   the   Criteria)  
medication)   o The   clinical   picture   is   dominated   by   three   (or   more)   of   the  
◦ Because   individuals   with   medical   conditions   often   following  symptoms:  
take  medications  for  those  conditions,  the  clinician   A.1. Stupor   -­‐   no   psychomotor   activity;   not   actively   relating   to  
must   consider   the   possibility   that   the   psychotic   environment  
symptoms   are   caused   by   the   physiological   A.2. Catalepsy   -­‐   passive   induction   of   a   posture   held   against  
consequences  of  the  medical  condition  rather  than   gravity  
the   medication,   in   which   case   psychotic   disorder   A.3. Waxy  flexibility  -­‐  slight  even  resistance  to  positioning  by  
due  to  another  medical  condition  is  diagnosed.     examiner  
A.4. Mutism   -­‐   no   or   very   little   verbal   response   [exclude   if  
◦ The   history   often   provides   the   primary   basis   for  
known  aphasia]  
such  a  judgment.  
A.5. Negativism  -­‐  opposition  or  no  response  to  instructions  of  
◦ At  times,  a  change  in  the  treatment  for  the  medical  
external  stimuli  
condition   (e.g.,   medication   substitution   or  
A.6. Posturing   -­‐   spontaneous   and   active   maintenance   of   a  
discontinuation)   may   be   needed   to   determine  
posture  against  gravity  
empirically   for   that   individual   whether   the  
A.7. Mannerism   -­‐   odd,   circumstantial   caricature   of   normal  
medication  is  the  causative  agent.    
actions  
◦ If   the   clinician   has   ascertained   that   the   disturbance   A.8. Stereotypy   -­‐   repetitive,   abnormally   frequent,   non-­‐goal  
is   attributable   to   both   a   medical   condition   and   directed  movements  
substance/  medication  use,   A.9. Agitation,  non-­‐influenced  by  external  stimuli  
▪ both  diagnoses  (i.e.,  psychotic  disorder  due  to   A.10. Grimacing  
another   medical   condition   and   substance/   A.11. Echolalia  -­‐  mimicking  another’s  speech  
medication-­‐induced   psychotic   disorder)   may   A.12. Echopraxia  -­‐  mimicking  another’s  movements  
be  given    
  Diagnostic  Features  
CATATONIA   Catatonia  associated  with  mental  disorder  (catatonia  
• Associated  with:   specifier)  
◦ Another  mental  disorder   • may   be   used   when   criteria   are   met   for  
▪ ex.   Neurodevelopmental,   psychotic,   bipolar,   catatonia   during   the   course   of   a  
depressive  or  mental  disorder   neurodevelopmental,   psychotic,   bipolar,  
◦ Catatonic   disorder   due   to   another   medical   depressive,  or  other  mental  disorder  
condition   • appropriate   when   the   clinical   picture   is  
◦ Unspecified  catatonia   characterized   by   marked   psychomotor  
• Defined   by   the   presence   of   3   or   more   of   12   disturbance   and   involves   at   least   three   of   the  
psychomotor   features   in   the   diagnostic   criteria   for   12  diagnostic  features  listed    in  Criterion  A  
catatonia   associated   with   another   mental   disorder   and   Catatonia  is  typically  diagnosed  in  an  inpatient  setting  
catatonic  disorder  due  to  another  mental  condition   and  occurs  in  up  to  35%  individuals  with  schizophrenia,  
Essential   feature   of   catatonia   is   marked   psychomotor   but   the   majority   of   cases   involve   individuals   with  
disturbance  that  may  involve:   depressive  or  bipolar  disorders.  
◦ Decreased  Motor  Activity   Before  the  catatonia  specifier  is  used,  a  wide  variety  of  
▪ severe  (stupor)   other   medical   conditions   need   to   be   ruled   out,     these  
conditions   include   but   are   not   limited   to   medical  
▪ or  moderate  (catalepsy  and  waxy  flexibility)  
conditions   due   to   infectious,   metabolic   or   neurological  
◦ Decreased   Engagement   During   Interview   Or  
conditions    
Physical  Examination  
Catatonia  can  also  be  a  side  effect  of  a  medication  
▪ severe  (mutism)   Because   of   the   seriousness   of   the   complications,  
▪ moderate  (negativism)   particular   attention   should   be   paid   to   the   possibility  
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 that   the   catatonia   is   attributable   to   neuroleptic   distress   or   impairment   in   social,   occupational   or   other  
malignant  syndrome.   medical  condition  is  unclear,  full  of  criteria  for  catatonia  
  are  not  met  or  there  is  insufficient  information  to  make  
Catatonic  Disorder  Due  to  Another  Medical  Condition   a   more   specific   diagnosis   (ex.in   emergency   room  
Diagnostic  Criteria   settings)  
A. [Same   with   the   Criterion   A   in   DSM   V   Criteria   for   Catatonia    
Associated   With   Another   Mental   Disorder   (Catatonia   OTHER  SPECIFIED  SCHIZOPHRENIA  SPECTRUM  AND  OTHER  
Specifier)]   PSYCHOTIC  DISORDER  
B. There   is   evidence   from   the   history,   physical   examination,   or   • This   category   applies   to   presentations   in   which   symptoms  
laboratory   findings   that   the   disturbance   is   the   direct   characteristic  of  a  schizophrenia  spectrum  and  other  psychotic  
pathophysiological  consequence  of  another  medical  condition   disorder   that   cause   clinically   significant   distress   or  
C. The   disturbance   is   not   better   explained   by   another   mental   impairment   in   social,   occupational,   or   other   important  
disorder  (ex.  a  manic  episode)   areas   of   functioning   predominate   but   do   not   meet   the   full  
D. The  disturbance  does  not  occur  exclusively  during  the  course   criteria  for  any  of  the  disorders  in  the  schizophrenia  spectrum  
of  a  delirium   and  other  psychotic  disorders  diagnostic  class.    
E. The   disturbance   causes   clinically   significant   distress   or   • used   in   situations   in   which   the   clinician   chooses   to  
impairment  in  social,  occupational  or  other  important  area  of   communicatethe  specific  reason  that  the  presentation  does  not  
functioning   meet   the   criteria   for   anyspecific   schizophrenia   spectrum   and  
  other  psychotic  disorder.    
Diagnostic  Features   • This   is   done   by   recording   “otherspecified   schizophrenia  
Essential   feature   is   the   presence   of   catatonia   that   is   spectrum   and   other   psychotic   disorder”   followed   by   the  
judged   to   be   attributed   to   the   physiological   effects   of   specificreason  (e.g.,  “persistent  auditory  hallucinations”).  
another  medical  condition   1. Persistent   auditory   hallucinations   occurring   in   the  
Diagnosed   by   the   presence   of   at   least   three   of   the   12   absence  of  any  other  features  
clinical  features  in  criterion  A  
2. Delusions   with   significant   overlapping   mood  
There   must   be   evidence   from   the   history,   physical  
episodesthat  are  present  for  a  substantialportion  of  the  
examination,   laboratory   findings   that   the   catatonia   is  
delusional   disturbance   (such   that   the   criterion  
attributable  to  another  medical  condition.  
stipulating   only   brief   mooddisturbance   in   delusional  
The   diagnosis   is   not   given   if   the   catatonia   is   better  
disorder  is  not  met).  
explained   by   another   mental   disorder   (ex.   manic  
3. Attenuated   psychosis   syndrome:   This   syndrome   is  
episode)  or  if  it  occurs  exclusively  during  the  course  of  a  
characterized   by   psychotic-­‐likesymptoms   that   are  
delirium  
below  a  threshold  for  full  psychosis  (e.g.,  the  symptoms  
 
are   lesssevere   and   more   transient,   and   insight   is  
Differential  Diagnosis  
relatively  maintained).  
• A   separate   diagnosis   of   catatonic   disorder   due   to   another  
4. Delusional   symptoms   in   partner   of   individual   with  
medical   condition   is   not   given   if   the   catatonia   occurs  
delusional   disorder:   In   thecontext   of   a   relationship,  
exclusively   during   the   course   of   a   delirium   or   neuroleptic  
the   delusional   material   from   the   dominant   partner  
malignant  syndrome.  
providescontent   for   delusional   belief   by   the   individual  
If   the   individual   is   currently   taking   neuroleptic  
who   may   not   otherwise   entirely   meet   criteriafor  
medication,   consideration   should   be   given   to  
delusional  disorder.  
medication-­‐induced  movement  disorders  (ex.  abnormal  
 
positioning   may   be   due   to   neuroleptic-­‐induced   acute  
dystonia)   or   neuroleptic   malignant   syndrome   (ex.   UNSPECIFIED  SCHIZOPHRENIA  SPECTRUM  AND  OTHER  
catatonia-­‐like   features   may   be   present   along   with   PSYCHOTIC  DISORDERS  
associated  vital  sign  and/or  laboratory  abnormalities)   • Used   in   situations   in   which   the   clinician   chooses   not   to   specify  
Catatonic   symptoms   may   be   present   in   any   of   the   the   reason   that   the   criteria   are   not   met   for   a   specific  
following  five  psychotic  disorders:   schizophrenia  spectrum  and  other  psychotic  disorder  
• Brief  psychotic  disorder   • Includes   presentations   in   which   there   is   insufficient  
• Schizophreniform  disorder   information   to   make   a   more   specific   diagnosis   (e.g.,   in  
• Schizophrenia   emergency  room  settings).  
• Schizoaffective  disorder    
• Substance/medication-­‐induced   psychotic   CULTURE-­‐BOUND  SYNDROMES  
disorder   • Specific   arrays   of   behavioral   and   experiential   phenomena  
It  may  also  be  present  in  some  of  neurodevelop-­‐mental   that   tend   to   present   themselves   preferentially   in   particular  
disorders  in  all  of  the  bipolar  and  depressive  disorders   sociocultural   contexts   and   that   are   readily   recognized   as  
and  in  other  mental  disorder   illness  behavior  by  most  participants  in  that  culture  
‘   • The   syndromes   are   commonly   assigned   culturally   sanctioned  
  explanations  and  interpretations  that,  in  turn,  generate  a  set  of  
Unspecified  Catatonia   culturally   congruent   remedies,   usually   in   the   form   of   healing  
Applies   to   presentations   in   which   symptoms   rituals   performed   by   someone   to   whom   the   community   assigns  
characteristics   of   catatonia   cause   clinically   significant   a  therapeutic  role.  

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• Treatment:  therapies,  collaboration  with  indigenous  healer      
• The  clinician  is  advised  to:     9. Hwa-­‐byung  (also  known  as  wool-­‐hwa-­‐byung):  
o Know  the  demographics     attributed   to   the   suppression   of   anger;   symptoms  
o Recognize  the  existence  of  a  local  pattern     include   insomnia,   fatigue,   panic,   fear   of   impending  
o Talk  to  family  and  learn  the  local  custom     death,   dysphoric   affect,   indigestion,   anorexia,   dyspnea,  
palpitations,   generalized   aches   and   pains,   and   a   feeling  
• Questions  to  be  asked  when  taking  the  history:      
of  a  mass  in  the  epigastrium  
o What  do  you  think  has  caused  your  problem?     10. Koro:  
o Why  do  you  think  it  started  when  it  did?     episode   of   sudden   and   intense   anxiety   that   the   penis  
o What  do  you  think  your  sickness  does  to  you?  How  does   (or,   in   women,   the   vulva   and   nipples)   will   recede   into  
it  work?     the  body  and  possibly  cause  death  
o How  severe  is  your  sickness?  Will  it  have  a  short  or   11. Latah:  
longcourse?     hypersensitivity  to  sudden  fright,  often  with  echopraxia,  
o What  kind  of  treatment  do  you  think  you  should   echolalia,   command   obedience,   and   dissociative   or  
receive?     trancelike   behavior;   more   frequent   in   middle-­‐aged  
  women  
Examples  of  Culture  Bound  Syndromes   12. Locura:    
EXAMPLES  OF  CULTURE-­‐BOUND  SYNDROMES   severe   form   of   chronic   psychosis;   attributed   to   an  
inherited   vulnerability,   to   the   effect   of   multiple   life  
Note:   Dr.   Joge   did   not   thoroughly   discuss   this   part.   He   just  
difficulties,  or  to  a  combination  of  both  factors  
enumerated   the   following   culture-­‐bound   syndromes.   If   you  
13. Mal  de  ojo:    
want   to   read   more   on   these   syndromes,   REFER   TO   KAPLAN’s  
fitful   sleep,   crying   without   apparent   cause,   diarrhea,  
TABLE  14.5-­‐1,  pp.523-­‐524  
vomiting  and  fever  in  a  child  or  infant  
  14. Nervios:    
1. Amok:     refers  both  to  a  general  state  of  vulnerability  to  stressful  
dissociative   episode   characterized   by   a   period   of   life   experiences   and   to   a   syndrome   brought   on   by  
brooding  followed  by  an  outburst  of  violent,  aggressive,   difficult   life   circumstances;   includes   a   wide   range   of  
or  homicidal  behavior  directed  at  persons  and  objects.   symptoms   of   emotional   distress,   somatic   disturbance,  
Precipitated  by  slight  insult   and  inability  to  function  
2. Ataque  de  nervios:   15. Piblokto:    
dissociative   experiences,   seizurelike   or   fainting   abrupt  dissociative  episode  with  extreme  excitement  of  
episodes,   and   suicidal   gestures   are   prominent   in   some   up   to   30   min.   and   frequently   followed   by   convulsive  
attacks  but  absent  in  others  general  feature  is  a  sense  of   seizures  and  coma  lasting  up  to  12  hrs  
being  out  of  control   person   may   be   withdrawn   or   mildly   irritable   for   hours  
3. Bilis  and  colera  (muina):     or  days  before  the  attack  and  typically  reports  complete  
due   to   strongly   experienced   anger   or   rage;   symptoms   amnesia  for  the  attack  
are   acute   nervous   tension,   headache,   trembling,   during  the  attack  they  may  tear  off  their  clothes,  break  
screaming,   stomach   disturbances,   and   severe   cases,   loss   furniture,   shout   obscenities,   eat   feces,   flee   from  
of  consciousness   protective   shelters,   or   perform   other   irrational   or  
4. Bouffe  delirante:     dangerous  acts  
a   sudden   outburst   of   agitated   and   aggressive   behavior,   16. Qi-­‐gong  psychotic  reactions:    
marked   confusion,   and   psychomotor   excitement;   may   acute,  time-­‐limited  episodes  of  dissociative,  paranoid,  or  
sometimes   be   accompanied   by   visual   and   auditory   other   psychotic   or   nonpsychotic   symptoms   that   may  
hallucinations  or  paranoid  ideation   occur   after   participation   in   the   Chinese   folk   health-­‐
5. Brain  fag:     enhancing  practice  of  qi-­‐gong  (exercise  of  vital  energy)  
a   condition   experienced   by   high   school   or   university   17. Rootwork  (mal  puesto  or  brujeria):    
students   in   response   to   the   challenges   of   schooling;   set   of   cultural   interpretations   that   ascribe   illness   to  
symptoms   include   difficulties   in   concentrating,   hexing,   witchcraft,   sorcery,   or   evil   influence   of   another  
remembering,  and  thinking   person;   symptoms   are   generalized   anxiety   and  
6. Dhat   gastrointestinal  complaints,  weakness,  dizziness,  fear  of  
severe   anxiety   and   hypochondriacal   concerns   being   poisoned,   and   sometimes   fear   of   being   killed  
associated   with   the   discharge   of   semen,   whitish   (voodoo  death)    
discoloration  of  the  urine,  and  feelings  of  weakness  and   18. Sangue  dormido  (sleeping  blood):    
exhaustion   pain,   numbness,   tremor,   paralysis,   convulsions,   stroke,  
7. Falling-­‐out  or  blackout:     blindness,  heart  attack,  infection,  and  miscarriages  
sudden   collapse,   which   sometimes   occurs   without   19. Shenjing  shuariuo  (neurasthenia):    
warming   but   is   sometimes   preceded   by   feelings   of   characterized  by  physical  and  mental  fatigue,  dizziness,  
dizziness   or   swimming   in   the   head;   the   person's   eyes   headaches,  other  pains,  concentration  difficulties,  sleep  
are   usually   open,   but   the   person   claims   an   inability   to   disturbance,   and   memory   loss;   may   include   GI  
see   problems,   sexual   dysfunction,   irritability,   excitability,  
8. Ghost  sickness:     and   various   signs   suggesting   disturbance   of   the  
a   preoccupation   with   death   and   the   deceased   autonomic  nervous  system    
(sometimes  associated  with  witchcraft)  
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   Antipsychotics  
20. Shen-­‐k'uei  (Taiwan);  shenkui  (China):     B. First  generation    
marked   anxiety   or   panic   symptoms   with   somatic   • Older  conventional    
complaints  with  no  physical  cause  demonstrated  
symptoms   include   dizziness,   backache,   fatigability,   • Dopamine  receptor  antagonists  
general   weakness,   insomnia,   frequent   dreams,   and  
complaints   of   sexual   dysfunction,   such   as   premature   • Usually  associated  with  extrapyramidal  side  effects  
ejaculation   and   impotence   attributed   to   excessive  
semen   loss   from   frequent   intercourse,   masturbation,   • Haloperidol  (Haldol,  Serenace)  5-­‐20  mg/day    
nocturnal   emission,   or   passing   of   white   turbid   urine  
believed  to  contain  semen.   SE:  EPS  
21.  Shin-­‐byung:     • Chlorpromazine  (Thorazine,  Psynor,  Laractyl)  100-­‐
syndrome   with   initial   phases   characterized   by   anxiety   600  mg/day  
and   somatic   complaints   (weakness,   dizziness,   fear,   GI  
problems),   with   subsequent   dissociation   and   SE:  sedation,  postural  hypotension  
possession  by  ancestral  spirits    
22. Spell:       C. Second  generation  
trance  state  of  persons  communicating  with  deceased   o Newer  drugs  
relatives   or   spirits;   maybe   associated   with   brief   periods  
of  personality  change   o Serotonin  dopamine  antagonists  (SDAs)  
23. Susto  (frigh  or  soul  loss):     • Risperidone  (Risperdal)  1-­‐4  mg/day  
illness  attributed  to  a  frightening  event  that  causes  the   1. Similar  to  Haloperidol,  thus  (+)  EPS  
soul   to   leave   the   body   resulting   in   unhappiness   and   • Clozapine  (Leponex)  100-­‐200  mg/day  
sickness;     1. No  EPS  
typical   include   appetite   disturbances,   inadequate   or   2. SE:  Agranulocytosis  
excessive   sleep,   troubled   sleep   or   dreams,   feelings   of   • Olanzapine  (Zyprexa)  5-­‐10  mg/day  
sadness,  lack  of  motivation  to  do  anything,  and  feelings   1. Highly  sedating  
of   low   self-­‐worth   or   dirtiness;   somatic   symptoms   2. SE:  Weight  gain,  exacerbation  of  pre-­‐existing  
include   muscle   aches   and   pains,   headache,   diabetes,  ↑sugar  level  
stomachache,  and  diarrhea   • Ziprasidone  (not  found  in  Philippines)  
24. Taijin  kyofu  sho:     • Quetiapine  (Seroquel)  200-­‐600  mg/day  
resembling   social   phobia   in   DSM;   the   syndrome   refers   1. Safe,  almost  no  side  effects  
to   an   intense   fear   that   one's   body,   its   parts   or   its   2. Prolongation  of  QT  interval  
functions,   displease,   embarrass,   or   are   offensive   to   • Amisulpride  (Solian)  50-­‐400  mg/day  
other  people  in  appearance,  odor,  facial  expressions,  or   • Aripiprazole  (Abilify)  5-­‐15  mg/day  
movements   1. Used  in  mood  problems  
25. Zar:       2. SE:   (+)   EPS   in   high   doses,   galactorrhea,  
the   experience   of   spirits   possessing   a   person;   with   amenorrhea  
dissociative   episodes   that   include   shouting,   laughing,   • Asenapine  (Saphris)  5-­‐10  mg/day  
hitting  the  head  against  a  wall,  singing,  or  weeping    
Shows   apathy   and   withdrawal,   refusing   to   eat   or   carry   Table  X.  Long  term  treatment  concerns.  
out  daily  tasks  or  may  develop  a  long-­‐term  relationship   Side  Effects  
with  the  possessing  spirit   Inc.  
  Drug   Weight   Extrapyramidal  
Plasma  
• pathology   and   an   electroencephalogram   to   determine   Gain   Symptoms  
Prolactin  
any  possible  seizure  disorders  (e.g.,  temporal  lobe  epilepsy).   Risperidone   ++   ++   +++  
•  Psychotic   disorder   caused   by   seizure   disorder   is   more   Olanzapine   +++   +   0  
common  than  that  seen  in  the  general  population.     Quetiapine   ++   0   0  
o It   tends   to   be   characterized   by   paranoia,  
Ziprasidone   0/+   +   0  
hallucinations,  and  ideas  of  reference.    
Aripiprazole   0/+   +   0  
• Patients   with   epilepsy   with   psychosis   are   believed   to  
 
have   a   better   level   of   function   than   patients   with  
Note:  Pls  refer  to  Appendix  for  detailed  discussion  of  each  drugs  
schizophrenic  spectrum  disorders.  
 
o  Better   control   of   the   seizures   can   reduce   the  
Benzodiazepine  
psychosis.  
  • decrease  agitation  during  acute  psychosis  
TREATMENT   • reduce  antipsychotics  needed  
 
Pharmacotherapy:  antipsychotics  are  the  mainstay  
Brands   of   drugs   are   those   that   are   available   in   the   Ph,   thus   are   Hospitalization  
important  to  take  note.   • Indicated  for  the  following:  
  • Diagnostic  purposes  
  • Stabilization  of  medications  
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 • Patient’s  safety  because  of  suicidal  or  homicidal    
ideation   Social  Therapy  
• Disorganized  or  inappropriate  behavior   • Sometimes  referred  to  as  behavioral  skills  therapy    
• Inability  to  take  care  of  basic  needs  (food,  clothing,   • Along  with  pharmacological  therapy,  this  therapy  can  
shelter)   be  directly  supportive  and  useful  to  the  patient.  
  • Behavioral  skills  training  addresses  behaviors  through  
o Establishing  an  effective  association  between  patients   the  use  of  videotapes  of  others  and  of  the  patient,  role  
and  community  support  system  is  the  primary  goal  of   playing  in  therapy,  and  homework  assignments  for  the  
hospitalization   specific  skills  being  practiced.  
  • Social  skills  training  has  been  shown  to  reduce  relapse  
Out-­‐Patient   rates  as  measured  by  the  need  for  hospitalization.  
o A  main  problem  of  out-­‐patient  management  is  loss  to    
follow-­‐up   Family-­‐Oriented  Therapy  
o Proper  instructions  as  to  when  to  come  back,  proper  
• Focus:  on  the  immediate  situation  and  should  include  
medication  regimen  is  important  to  improve  compliance  
identifying  and  avoiding  potentially  troublesome  
o “In  out-­‐patient,  you  can  almost  do  everything  already.”  
situations  
o Biological  treatments  
• When  problems  do  emerge  with  the  patient  in  the  
o Psychosocial  therapy  
family,  the  aim  of  the  therapy  should  be  to  resolve  the  
o Social  therapy  etc.  
problem  quickly  
o The  challenge  is  how  to  make  the  patient  see  you  
indefinitely,  how  to  make  the  patient  take  medications   • Family  should  be  advised  not  to  ask  pt  to  resume  
indefinitely  especially  in  chronic  cases   regular  activities  too  quickly  
• Therapists  must  help  both  the  family  and  the  pt  
 
understand  &  learn  about  schizophrenia  
Psychosocial  Therapy  
• Must  encourage  discussion  of  the  psychotic  episode  and  
• Include  a  variety  of  methods  to  ↑  social  abilities,   the  events  leading  up  to  it  
selfsufficiency,  practical  skills,  &  interpersonal   • Ignoring  the  psychotic  episode,  a  common  occurrence,  
communication  in  schizophrenia  patients   often  increases  the  shame  associated  w/  the  event  &  
• Goal:  to  enable  persons  who  are  severely  ill  to  develop   does  not  exploit  the  freshness  of  the  episode  to  
social  and  vocational  skills  for  independent  living   understand  it  better  
• Carried  out  at  many  sites:  hospitals,  outpatient  clinics,   • Talking  openly  w/  the  psychiatrist  and  w/  the  relative  
mental  health  centers,  day  hospitals,  and  home  or  social   w/  schizophrenia  often  eases  fears  of  all  parties  
clubs   • Directs  family  therapy  toward  long-­‐range  application  of  
GOALS  AND  TARGETED  BEHAVIORS  FOR  SOCIAL  SKILLS   stress-­‐reducing  &  coping  strategies  &  toward  the  
THERAPY   patient's  gradual  reintegration  into  everyday  life  
PHASE   GOALS   TARGETED   • Must  control  the  emotional  intensity  of  family  sessions  
BEHAVIORS   w/  pt.  
Stabilization   Establish  therapeutic   Empathy  and  rapport   • Excessive  expression  of  emotion  during  a  session  can  
and   alliance   Verbal  and  nonverbal   damage  a  pt's  recovery  process  and  undermine  
assessment   Assess  social   communication   potentially  successful  future  family  therapy.  
performance  and   • Especially  effective  in  reducing  relapses.  
perception  skills    
Assess  behaviors  that   References  
provoke  expressed  
• Doc  Joge’s  PPT  and  lecture  
emotion  
• American  Psychiatric  Association.  (2013).  Diagnostic  
Social   Express  positive   Compliments,  
and  Statistical  Manial  of  Mental  Disorders  (5th  ed.).  
performance   feelings  within  family   appreciation,  interest  
Washington,  D.C.  
within  family   Teach  effective   in  others  
LET’S  GO  BATCH  2019!  100%  PROMOTION!  
strategies  for  coping   Avoidance  response  
#2019KAKAYANIN  #ROADTOCLERKSHIP  
with  conflict   to  criticism,  stating  
preferences  and    
refusals    
Social   Correctly  identify   Reading  a  message    
perception  in   content,  context,  and   Labeling  an  idea    
the  family   meaning  of  messages   Summarizing  other's    
intent    
Extrafamilial     Enhance  socialization   Conversational  skills    
relationships   skills   Dating  Recreational  
 
Enhance  prevocational   activities,  Job  
 
and  vocational  skills   interviewing,  work  
habits    
Maintenance   Generalize  skills  to  new  situations  
16  of  x  
[Capalaran,  De  Gracia,  Dungca,  Maki,  Zaguirre]