Delusions of guilt: Belief that one is guilty or responsible for

something. Example: “I am responsible for all the world’s wars.”

Somatic delusions: Belief that one has a certain illness or health

condition. Example: A patient believing she is pregnant despite
negative pregnancy tests and ultrasounds.
PERCEPTUAL DISTURBANCES
Illusion: Misinterpretation of an existing sensory stimulus (such as
mistaking a shadow for an evil spirit).

Hallucination: Sensory perception without an actual external stimulus.

Hallucination
Auditory: The most common modality experienced by patients with
schizophrenia.
Visual: Occurs in schizophrenia and other psychotic disorders, but less
common. May accompany drug intoxication, drug and alcohol
withdrawal, or delirium.
Olfactory: Usually an aura associated with epilepsy.
Tactile: Usually secondary to drug intoxication (e.g., cocaine or
psychostimulants) or alcohol withdrawal.
DIFFERENTIAL DIAGNOSIS OF
PSYCHOSIS
Psychotic disorder due to another medical condition.
Substance/Medication-induced psychotic disorder.
Delirium/Major neurocognitive disorder (dementia).
Bipolar disorder, manic/mixed episode.
Major depressive disorder with psychotic features.
Brief psychotic disorder.
Schizophrenia.
Schizophreniform disorder.
Schizoaffective disorder.
Delusional disorder
Schizophrenia
Schizophrenia is a psychiatric disorder characterized by a
constellation of abnormalities in thinking, emotion, and behavior.
There is no single symptom that is pathognomonic, and there is a
heterogeneous clinical presentation.
Schizophrenia is typically chronic, with significant psychosocial and
medical consequences to the patient
 POSITIVE, NEGATIVE, AND COGNITIVE
SYMPTOMS

In general, the symptoms of schizophrenia are broken up into three

categories:
Positive symptoms: Hallucinations, delusions, bizarre behavior,
disorganized speech. These tend to respond more robustly to
antipsychotic medications.
Negative symptoms: Flat or blunted affect, anhedonia, apathy, alogia,
and lack of interest in socialization. These symptoms are comparatively
more often treatment resistant and contribute significantly to the social
isolation and impaired function of schizophrenic patients.
Cognitive symptoms: Impairments in attention, executive function, and
working memory. These symptoms may lead to poor work and school
performance.
Think of positive symptoms as things that are ADDED
onto normal behavior.

Think of negative symptoms as things that are

SUBTRACTED or missing from normal behavior.
 The 5 A’s of schizophrenia (negative symptoms):
1. Anhedonia
2. Affect (flat)
3. Alogia (poverty of speech)
4. Avolition (apathy)
5. Attention (poor)
THREE PHASES
Symptoms of schizophrenia often present in the following three phases:

1. Prodromal: Decline in functioning that precedes the first

psychotic episode. The patient may become socially withdrawn
and irritable. They may have physical complaints, declining
school/work performance, and/or newfound interest in religion or
the occult.
2. Psychotic: Perceptual disturbances, delusions, and disordered
thought process/content.
3. Residual: Occurs following an episode of active psychosis. It is
marked by mild hallucinations or delusions, social withdrawal, and
negative symptoms.
 DIAGNOSIS OF SCHIZOPHRENIA

DSM-5 Criteria
Two or more of the following must be present for at least 1 month:
1. Delusions.
2. Hallucinations.
3. Disorganized speech.
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms.
Note: At least one must be 1, 2, or 3.

Must cause significant social, occupational, or functional (self-care)

deterioration.
Duration of illness for at least 6 months (including prodromal or
residual periods in which the above full criteria may not be met).
Symptoms not due to effects of a substance or another medical
condition.
Brief psychotic disorder lasts for <1 month.

Schizophreniform disorder can last between 1 and 6

months.

Schizophrenia lasts for >6 months.

Schizophrenia affects approximately 0.3–0.7% of people over their
lifetime.
Men and women are equally affected.
Post-psychotic depression is the phenomenon of schizophrenic
patients developing a major depressive episode after resolution of
their psychotic symptoms.
 PATHOPHYSIOLOGY OF SCHIZOPHRENIA:
THE DOPAMINE HYPOTHESIS

Though the exact cause of schizophrenia is not known, it appears

to be partly related to increased dopamine activity in certain
neuronal tracts.

Evidence to support this hypothesis is that most antipsychotics

successful in treating schizophrenia are dopamine receptor
antagonists. In addition, cocaine and amphetamines increase
dopamine activity and can cause schizophrenia-like symptoms.
OTHER NEUROTRANSMITTER ABNORMALITIES IMPLICATED IN
SCHIZOPHRENIA

Elevated serotonin
Elevated norepinephrine
Low gamma-aminobutyric acid (GABA)
Low levels of glutamate receptors
TREATMENT
A multimodal approach is the most effective, and
therapy must be tailored to the needs of the
specific patient.
Pharmacologic treatment consists primarily of
antipsychotic medications.
Schizophreniform Disorder
The diagnosis of schizophreniform disorder is made using the same
DSM-5 criteria as schizophrenia. The only difference is that in
schizophreniform disorder the symptoms have lasted between 1 and
6 months, whereas in schizophrenia the symptoms must be present
for >6 months.

One-third of patients recover completely; two-thirds progress to

schizoaffective disorder or schizophrenia.
Schizoaffective Disorder
The diagnosis of schizoaffective disorder is made in patients who:
Meet criteria for either a major depressive or manic episode
during which psychotic symptoms consistent with schizophrenia
are also met.

Have delusions or hallucinations for 2 weeks in the absence of

mood disorder symptoms (this criterion is necessary to
differentiate schizoaffective disorder from a mood disorder with
psychotic features).

Have mood symptoms for a majority of the psychotic illness.

Brief Psychotic Disorder
Patient with psychotic symptoms as in schizophrenia; however,
the symptoms last from 1 day to 1 month, and there must be
eventual full return to premorbid level of functioning.
Symptoms must not be due to the effects of a substance (drug
or medication) or another medical condition.
This is a rare diagnosis, much less common than schizophrenia.
It may be seen in reaction to extreme stress such as
bereavement and sexual assault.
Delusional Disorder
Delusional disorder occurs more often in middle-aged or
older patients (after age 40).
Immigrants, the hearing impaired, and those with a family
history of schizophrenia are at increased risk.
To be diagnosed with delusional disorder, the following criteria must
be met:
One or more delusions for at least 1 month.
Does not meet criteria for schizophrenia.
Functioning in life not significantly impaired, and behavior not
obviously bizarre.
 Schizophrenia versus Delusional
Disorder
Delusional Disorder
Schizophrenia
Bizarre or nonbizarre delusions Usually nonbizarre delusions
Daily functioning significantly
impaired Daily functioning not
significantly impaired.
Must have two or more of the
following: Does not meet the criteria for
■ Delusions schizophrenia.
■ Hallucinations
■ Disorganized speech
■ Disorganized behavior
■ Negative symptoms
Types of Delusions
Patients are further categorized based on the types of delusions they
experience:
Erotomanic type: Delusion that another person is in love with the
individual.
Grandiose type: Delusions of having great talent.
Somatic type: Physical delusions.
Persecutory type: Delusions of being persecuted.
Jealous type: Delusions of unfaithfulness.
Mixed type: More than one of the above.
Unspecified type: Not a specific type as described above.
Prognosis
Better than schizophrenia with treatment:
>50%: Full recovery.
>20%: Decrease in symptoms.
<20%: No change
Prognosis from Best to Worst

Mood disorder with psychotic features > schizoaffective

disorder > schizophreniform disorder > schizophrenia.
QUICK AND EASY DISTINGUISHING
FEATURES
Schizophrenia: Lifelong psychotic disorder.
Schizophreniform: Schizophrenia for >1 and <6 months.
Schizoaffective: Distinct mood episodes with psychosis persisting
between mood episodes.
Schizotypal (personality disorder): Paranoid, odd or magical
beliefs, eccentric, lack of friends, social anxiety. Criteria for overt
psychosis are not met.
Schizoid (personality disorder): Solitary activities, lack of
enjoyment from social interactions, no psychosis.