Schizophrenia and other psychotic disorders

Psychoses are the most serious psychiatric disorders known. Someone who is psychotic has experiences and beliefs that are difficult for other people to understand and that make him live, as it were, in a world of his own. This also changes his behavior, language use and interaction with fellow humans. This article discusses the various psychotic disorders, especially Schizophrenia.

Classification of psychotic disorders

Psychosis often involves a lack of insight and awareness of illness, especially in the beginning. A disturbed sense of reality is therefore seen as a central feature of psychosis. But this is not entirely correct, because the experience of reality can also be distorted with other psychiatric conditions (e.g. depression (seeing everything black), anorexia (wrong body image). Healthy people also sometimes suffer from experiences that resemble that of psychiatric patients.

Psychotic symptoms

Psychotic symptoms include:

  • Delusions
  • Hallucinations
  • Incoherence and other disorders of thought.
  • Catatonic movement disorders
  • Severely disordered behavior.

The first two are the most important. The demarcation between other patients and healthy people is not clear-cut and is a matter of degree.
The field of psychotic disorders is divided in the DSM-IV into:

  • Schizophrenia
  • Schizophreniform disorder
  • Schizoaffective disorder
  • Delusional disorder
  • Short-term psychotic disorder
  • Shared psychotic disorder
  • Psychotic disorder due to a general physical condition
  • Psychotic disorder due to substance use.

All psychotic disorders occur in both men and women.

Schizophrenia

Emerging in adolescence or early adulthood, it is characterized by psychotic episodes alternating with calmer phases in which the patient functions at a much more limited level than prior to the onset of the disease. Schizophrenia is a heterogeneous disorder:

  • Varying clinical pictures;
  • Variable gradient;
  • Multitude of biological abnormalities.

As a result, schizophrenia is not called a disease entity but a syndrome.
Schizophrenia is distinguished from:

  • Psychotic disorders of short duration and with a favorable course (schizophreniform disorder or short-term psychotic disorder.)
  • Psychoses that, although tending to chronicity, do not seriously affect the general level of functioning (delusional disorder)
  • Psychotic disorders associated with significant mood disturbance (schizoaffective disorder or mood disorder with psychotic features)
  • Personality disorders that are symptomatologically related to schizophrenia, but that do not reach the proportions that fit this diagnosis (schizotypal personality disorder or schizoid and paranoid personality disorder)

 

Characteristics and appearance

Origin and course
Origin in adolescence or early adulthood. Onset can be quite acute (for example after an important event), but also often gradual. With gradual development it is difficult to indicate the beginning afterwards, because the initial characteristics are difficult to distinguish from behavior that may be normal during puberty: daydreaming, withdrawing to one’s own room, strange interests, inadequate emotional reactions, etc. The contact is usually chaotic, bizarre, agitated, or withdrawn. Some react irritably and unpredictably, others passively and barely react. Movement is disrupted (lack of movement or unusual movements). Self-care falls short. The clinical picture is very varied. Psychotic episodes alternate with calm episodes. Schizophrenia never goes away. More stabilization later in life. First ten years of disease process most turbulent.
Positive and negative symptoms
Two symptom clusters: positive and negative symptoms:
1. Positive symptoms: symptoms that should not be there: delusions, hallucinations, incoherence. The positive syndrome is also divided into:

  • Disturbed sense of reality (delusions and hallucinations)
  • Cognitive disorganization (incoherence): disorders of perception and thinking.
  1. Negative symptoms: the absence of behaviors or experiences that are normally present: emotional flattening, social withdrawal behavior, loss of initiative and lack of speech. Predominantly behavioral disorders. Negative symptoms are much less noticeable than the positive ones. Most evident in chronic patients. Sometimes difficult to distinguish from depressive symptoms or side effects of medications.

Thought disorders

The most important positive symptoms are the formal and substantive thought disorders, in which the form and content of thinking are disturbed, respectively.
The most striking formal thought disorder is incoherence: the patient jumps from one thing to another and cannot make sense of the train of thought. Abstract concepts are sometimes explained in concrete terms. Sometimes a patient creates new words (neologisms). Sometimes we see echolalia (meaningless repetition of self-pronounced words). Thinking may also be slowed, and sometimes there are thought blocks.
The most common substantive thought disorder is delusion. And delusion is a fixed and very personal belief that is no longer shared by others and is held on to without sufficient basis and despite evidence of its falsity.

  • If the patient admits any doubt, this is called a delusional view.
  • A delusion is sometimes preceded by a period of tense uncertainty about the meaning of what is happening. That’s called a delusional mood.
  • A delusion that arises without any reason is called a primary delusion.
  • Secondary delusions arise from misunderstood experiences, such as hallucinations that require explanation, or other difficult-to-understand experiences.
  • Sometimes there is a whole complex of coherent delusions: a delusional system.
  • We speak of delusional perception when observations that are in themselves correct are given an unusual and very personal meaning.

Certain delusional themes are typical of schizophrenia: these are themes in which the integrity of one’s own person and world of thought is threatened, in which the ego boundaries are damaged, and in which control over one’s own thoughts has disappeared.

  • Delusions in which the patient believes that thoughts are being put into his head from outside or in which he believes that others can hear his thoughts.
  • Delusions of influence: the patient has the idea that his own thoughts, feelings and actions are controlled by an outside force, so that he feels at the mercy of it, like a kind of robot.
  • Delusion that he can influence an event elsewhere (e.g. a football match on TV)
  • Delusion in which a patient literally experiences himself as disintegrated, or believes that a transmitter has been implanted in his body.

More normal delusions (such as paranoid delusions):

  • Beliefs that the patient feels threatened, chased, or overheard. (this also happens in reality)
  • Delusions of a religious, erotic, jealous or grandiose character.
  • Delusions of Relation: A person thinks that trivial events affect him. (that the newsreader on TV addresses him specifically)

If it is a feeling, and not an absolute certainty, we call it a relationship idea (someone who has the idea that people are talking about him on the terrace). Delusions of schizophrenia patients have a bizarre character. They are so improbable that it is not at all conceivable that they could be true.
How should we understand delusions? Some say that they are theories that people come up with to add meaning to the surrounding or internally experienced reality. The patient’s subjective experience is always central.

Perceptual disturbances

Perceptual disturbances are also among the most important positive symptoms. Hallucinations are sensory perceptual experiences without an external source for that perception, while the patient is still absolutely convinced of it. They can occur for all sensory functions, most commonly auditory hallucinations and less often facial hallucinations.
An illusion is a perception of something that is actually there, but is misinterpreted. A distinction is made between real and pseudohallucinations . In pseudohallucinations, the hallucinatory experiences have an as-if character: there is doubt, not certainty.
Hallucinations can be simple or complex, and range from flashes of light or shadows, whistling or humming, to images or voices. The hallucinations most characteristic of schizophrenia consist of hearing voices.
Hearing your own thoughts spoken out loud in your head. These are introduced thoughts or hallucinations when the patient does not know that they are his own thoughts.

  • Voices are often personal and intrusive.
  • Imperative hallucinations: voices giving commands.
  • Sometimes several voices talk to each other about the patient and comment on behavior or thoughts.

How should we understand hallucinations? Hallucinations can be seen as unconscious mental activity entering consciousness. These people are more suggestible and are more likely to think they see a meaning in something that in fact is not there. Auditory hallucinations are accompanied by subvocalizations: muscle activity in the lips and chin appears to be increased during hallucination.

Emotional disorders

The mood and emotional responses are often dysregulated in schizophrenia: anxious and irritable, especially in acute periods. The emotional reactions sometimes do not seem to fit the situation (inadequate affect). Depressive episodes often arise after a psychotic period: a post-psychotic depression. However, the most characteristic feature of schizophrenia is the affective flattening/emotional blunting. Usually occurs later.

Cognitive disorder

Problems processing impressions from the environment. Is most evident during an acute psychotic episode. Attention is disturbed, wanders easily and often cannot be focused on a subject for long. Too many impressions poses a threat of overwhelm, because they cannot process them, but too few impressions can lead to a revival of hallucinations and anxious thoughts.

Behavioral and movement disorders

During acute and confused periods, patients with schizophrenia can be very restless. As the disease progresses, they often become less active, initiative disappears and apathy can determine behavior. Characteristic movement disorders are catatonic symptoms. These are not specific to schizophrenia. The flexibility of the movements is affected and control seems to have been given away.

  • Stupor: motionless and sometimes unable to speak (mutism).
  • Negativism: when he automatically does the opposite of what is asked.
  • Catalepsy: the unwillingness to accept and maintain a position in which the patient has been placed, without being aware of it.
  • Remarkable postures are sometimes chosen by themselves and maintained for a long time. E.g. pointless repeat movements.
  • Mannerism: when the movements make an exaggerated impression.
  • Grimacing: the adoption of strangely rigid facial expressions.
  • Echopraxia and echolalia: senseless imitation of someone else’s movements or words.
  • Ambition: When the patient cannot decide whether or not to make a certain movement. He then alternates between both options without completing them.

 

Insight and awareness of illness

The patient has lost control: control over his thoughts (incoherence), over his thinking (delusions), over his perception (hallucinations), over his movements (catatonic features), over his social behavior (negative syndrome). Limited and sometimes no insight into the nature of the condition. They can, however, tell you about symptoms.

Diagnostics

Different types of schizophrenia that are not easily distinguished from each other (DSM-IV):

  • Catatonic type: dominated by catatonic symptoms. Rare.
  • Disorganized or hebephrenic type: striking presence of incoherence or seriously dysregulated behavior and also of flattened or inadequate affect.
  • Paranoid type: preoccupation with one or more delusions or with frequent auditory hallucinations. Striking incoherence, affect disturbances and catatonic behavioral disturbances are absent. Most common.
  • Undifferentiated type: the clinical picture does not fit neatly into any of the previous categories.
  • Residual state type: absence of prominent delusions, hallucinations, incoherence, or severely disordered behavior. Such symptoms have been present during a psychotic episode, but at this point they are only residual symptoms. Negative symptoms in the foreground.

In ICD-10 these are added:

  • Postschizophrenic depression: a depressive period following a schizophrenic-psychotic period.
  • Schizophrenia simplex: rare picture. Gradually and insidiously, a negative syndrome develops, without clear positive psychotic symptoms.

 

Differential diagnostics

Numerous neurological disorders may be associated with syndromes that are reminiscent of schizophrenia and are clinically difficult to distinguish from schizophrenia.

  • Temporal epilepsy
  • Central nervous system infections
  • Huntington’s disease
  • Multiple sclerosis
  • Cerebrovascular disorders

In such cases, organic abnormalities are unmistakable, so the diagnosis of schizophrenia is not eligible. Further:

  • Psychotic symptoms reminiscent of schizophrenia can also occur in somatic syndromes that secondarily disrupt cerebral functions: infections, hypo- and hyperthyroid, autoimmune diseases, etc.
  • All kinds of psychoactive substances.

If there are psychotic symptoms, an organic cause must first be ruled out: a careful history and a physical examination. If a somatic cause has been ruled out, we look at how long the symptoms have existed. If psychotic symptoms are characteristic of schizophrenia, without noticeable mood disorders, with deteriorated functioning, and there have been psychotic, prodromal or residual symptoms for at least six months, this points to the diagnosis of schizophrenia.

Epidemiology

The risk that someone will develop schizophrenia at some point in their life is just under 1%. The average age for women is higher than for men. Rarely occurs before puberty or after middle age. Schizophrenia is not culture-bound. The progression is more favorable in less developed countries than in western industrialized countries. Risk factors: influenza (flu) or rubella (rubella) during pregnancy, famine experienced in the womb, severe stress from mother during pregnancy, lack of oxygen during delivery, cannabis use by the person, second generation immigrants (stress due to adaptation to culture), growing up in a big city.
Scientific insights
Schizophrenia is a complex illness that does not have a single cause: it is a heterogeneous disorder.
The vulnerability model:

  • Vulnerability consists of enduring characteristics that make some people more sensitive to the risk of a psychiatric illness. This vulnerability is genetically determined.
  • Stress is a global term to indicate stressful influences from the environment that require adjustment.
  • This model assumes that schizophrenia is the result of an interaction between specific sensitivity and stressful factors. The latter mainly have a luxating influence: without the presence of specific vulnerability, schizophrenia does not arise.

There are no indications that psychological or environmental factors (upbringing or social circumstances ) in themselves can be responsible for the development of vulnerability to schizophrenia. Social factors do have an influence.

Genetic factors

Hereditary factors are very important. The risk of developing schizophrenia themselves is approximately ten times higher for first-degree relatives of a patient with schizophrenia than for the average population. Genetic vulnerability is determined by several genes. This threshold value must be exceeded. Research is being conducted into candidate genes. Among biological relatives of patients with schizophrenia, all kinds of variations on the theme of schizophrenia are increasingly common, including milder psychoses, schizoaffective images and people with schizotypal personality traits. This whole is called the schizophrenia spectrum. The genetic research also shows that many people who should have the vulnerability do not develop any noticeable psychiatric symptoms. More than just predisposition is therefore required for the development of schizophrenia.

Neurobiological abnormalities

The dopamine hypothesis assumes a hyperactivity of dopaminergic systems. Support for this comes from two important observations:

  • Antipsychotic medications all block dopamine D2 receptors to an extent that correlates with clinical efficacy.
  • Secondly, substances that stimulate dopaminergic stimulus transmission (amphetamine-like substances) appear to be able to provoke psychoses that can closely resemble schizophrenia.

Overactive dopaminergic systems therefore play a role in psychoses, but they do not explain the development of schizophrenia.
The volume of the lateral ventricles is increased in people with schizophrenia. The volume of the brain as a whole is reduced , especially the volume of the hippocampus (already in early schizophrenia). In many patients, subtle neurological abnormalities are demonstrable: less adequate integration of different types of information. Frontal areas appear underactive.
Furthermore, disorders in attention, memory and planned action: frontal and temporal functions. This may be an expression of vulnerability to schizophrenia. Can also be demonstrated to some extent in first-degree relatives.

Therapy

Modern trade policy: a package of biological, psychological and social interventions. In the narrower sense of the therapeutic approach (aimed at combating symptoms), the rehabilitation approach (aimed at optimal adaptation to realistic goals in life) occupies an important place. Also antipsychotic medications.

Medication

The older drugs are known as classical or first-generation antipsychotics. The more recent drugs are sometimes called atypical or second-generation antipsychotics. Antipsychotics are effective and are an indispensable part of the treatment. The clinical effects are the reduction of positive psychotic symptoms. Negative symptoms respond much less well. Commonly used first-generation drugs are haloperidol, zuclopenthixol and pimozide. Commonly used drugs of the second generation are: olanzapine, risperidone, quetiapine and clozapine. The first-generation drugs more often lead to movement disorders, the so-called extrapyramidal side effects (including parkinsonism, dyskinesia, etc.). It is common to aim for maintenance medication and not to stop all at once when things improve.

Psychosocial treatments

Although pharmacotherapy is an indispensable part of the treatment, psychological and social interventions and support are also of paramount importance. With assertive community treatment (ACT), the patient receives continuous care from a permanent team. Medication compliance receives a lot of attention. Systematic information and psychoeducation about the disease, the limitations, the risks (cannabis) and the treatment is common nowadays. Family interventions, focused on support and problem solving, can be effective. Training social skills and cognitive skills does not seem to be very effective. Symptom management and cognitive behavioral therapy are useful. Almost all patients with schizophrenia spend a short or longer period in the psychiatric hospital. The nature of the clinical picture of schizophrenia sometimes makes it inevitable that a patient is involuntarily admitted. The law offers various options for this.

Prognosis

The course of schizophrenia in less developed countries is more favorable than in the developed West. The transcultural differences are intriguing. Drug use is common in patients with schizophrenia. These have a negative influence. There are many factors that influence the course of the disease and none of them has a predominant significance. Indicative of a poor prognosis are:

  • Gradual onset of the disease
  • No triggering factors
  • Start at a young age
  • Poor functioning before the disease
  • Negative symptoms
  • No depressive features
  • Schizophrenia in the family.

Approximately a quarter of patients appear to have complete symptomatology over longer periods of time. A permanent psychotic state is not very common. Usually periods of psychotic revival, alternating with calm periods. Over time, many patients become flat, the restlessness and agitation decrease and negative symptoms often dominate the picture. Ten percent die by suicide.

Non-schizophrenic psychoses:

Schizophreniform disorder

Characteristics and appearance

The term schizophreniaform is used for psychoses that resemble schizophrenia in symptoms, but have a more favorable course. The DSM-IV refers to a schizophreniform disorder if the picture is that of schizophrenia, but the time criterion of six months is not met. This disorder is less common than schizophrenia.
Scientific insights It appears that this diagnostic concept includes a collection of heterogeneous syndromes, largely related to schizophrenia.

Therapy

Antipsychotic medication supplemented with psychosocial interventions. A benign course. As it becomes necessary to continue giving antipsychotics for a long period of time, the diagnosis of schizophrenia becomes more likely.

Prognosis

The course is more favorable than that of schizophrenia. Relapses are possible, but the level of functioning between episodes is not as affected as in schizophrenia.

Schizoaffective disorder

Characteristics and appearance

When one sees mixed images of schizophrenic characteristics and symptoms of a mood disorder. This is a heterogeneous category about which there is still a lot of controversy. It includes: severe mood disorders with strong mood-incongruent psychotic experiences and relatively favorable schizophrenic disorders with significant mood dysregulation.
Schizoaffective disorder may include a manic (bipolar) component (schizomania) or a depressive component (schizodepression).

Scientific insights

The clinical picture is heterogeneous.

Therapy

Related to the treatment of schizophrenia and bipolar or non-bipolar mood disorders. Generally antipsychotic medication. The bipolar type of lithium or another mood stabilizer also seems to have an effect. This results in a combination treatment. Antidepressants can be given for the depressive type. Also psychosocial interventions.

Prognosis

The course lies between that of schizophrenia and a mood disorder. Psychotic symptoms that do not correspond to mood have a negative influence on the psychosis. As the schizophrenic symptomatology becomes more prevalent, the prognosis will be less favorable. The more impressive the mood disorder is, the better the prognosis in terms of social functioning. There is also still a risk of relapse.

Delusional disorder

Characteristics and appearance

A group of psychoses that have in common a persistent non-bizarre delusion (i.e. it could be true), while general functioning remains relatively intact. Hallucinations can occur, but at most occasionally. It is typical that the delusion is not impossible in the patient’s cultural context, although indications for this are completely lacking and the delusional belief cannot be corrected in any way. The distinction with schizophrenia therefore lies in the substantive features of the delusion, in the virtual absence of other psychotic symptoms and in the omission of serious social dysfunction. The following variants of delusional disorders are distinguished:

  • Erotic delusions of relationship: the central theme is the certainty that someone of high status is in love with the person involved (usually a woman). All kinds of explanations are given for the lack of evidence that leave the belief intact. People also speak of erotomania.
  • Delusions of grandeur: The theme is the patient’s belief that he is extremely important, extremely intelligent, an inventor, of royal blood, or perhaps has a special relationship to a deity. Is often an attempt to give life meaning.
  • Delusions of jealousy: the certainty that the partner is unfaithful: another name is also delusions of infidelity. The partner’s attempts to prove his or her guilt fail. This is only seen as confirmation: Why would he explain it differently?
  • Delusion of persecution: in the foreground is the belief that one is being harmed, being chased and spied on, or perhaps even having one’s life attempted. Also called paranoid delusional disorder.
  • Somatic delusion: central is the patient’s certainty that he has an illness or defect, often of a serious nature. Hypochondriac delusions (cancer, AIDS, infectious diseases)
  • Average age of onset of delusional disorder is 40 years. Acute and gradual onset possible.

 

Scientific insights

The category and etiology are heterogeneous. Genetic factors appear to play a role. However, extremely little is known with certainty about its origins and contributing factors. Theories about this largely coincide with theories about the etiology of delusions in general. Delusions are common, are not specific to a particular psychotic disorder and can also occur in organic psychiatric syndromes and mood disorders. You have to look at the culture and religion of the person with the delusion. Those are both important. The extent to which the view is personal, not shared with others, is decisive. When is it a belief and when a delusion? Unclear.

Therapy

Patients usually lack a need for treatment. The thoughts of a psychiatric disorder are strongly rejected. If treatment contact is established, this often happens indirectly, for example via the police or somatic health care. Sometimes an involuntary admission. Difficult to establish a therapeutic relationship due to suspicion and defensiveness. Often the delusion is not addressed directly, but rather the events that result from it. This is more accepted by patients. Cognitive-behavioral interventions with limited objectives, aimed at breaking vicious circles, can be useful. There are differing opinions about the effectiveness of antipsychotics in delusional disorders. When the delusion is part of a serious mood disorder, antidepressants are useful (in that case a combination of antidepressants and antipsychotics).

Prognosis

In general, it is not associated with significantly poorer social functioning.

Short-term psychotic disorder

Characteristics and appearance

A psychotic reaction can pass quickly. Then there is often (but not always) a clear reason. Some benign psychoses are provoked by a very stressful experience that immediately precedes the psychosis. Examples are confrontation with war violence, rape or natural disasters, but also loss of partner or job. This is the least serious psychotic disorder. The only requirement is that at least one psychotic symptom is present for at least a day, but less than a month: a delusion, a hallucination, a formal thought disorder or seriously disordered behavior. Furthermore, it is important to function properly until the moment of decompensation, the presence (sometimes) of intense and changing emotions and the usually rapid improvement.

Scientific insights

Little is known about the etiology. No genetic relationship with schizophrenia or delusional disorder. A certain predisposition plays a role, the nature of this is unclear.

Therapy

Care in a quiet environment and supportive conversations. Psychotic symptoms then quickly disappear. Furthermore, antipsychotic medications or benzadiazepine for anxiety.

Prognosis

Prognosis is favorable. Course is benign. No residual symptoms.

Shared psychotic disorder

Characteristics and appearance

This is a delusion that arises in someone who is in a close relationship with another person who has previously developed the same delusion. Rare. Usually delusions with paranoid content and with some systematization. Usually family members or people who interact intensively with each other.

Scientific insights

The source of the delusion, the inducer, is the dominant partner, who, as it were, drags the dependent and suggestible other along. Striking social isolation, self-chosen or due to circumstances. This makes external testing of the delusion difficult.

Therapy

Separating various participants in the delusion, so that the delusion may disappear into the background. Furthermore, the same policy as Andre psychotic disorders. Inductor (beginner) is the most difficult to treat. He/she usually has schizophrenia.

Prognosis

The prognosis is not unfavorable when contact with the source is broken.

Atypical psychoses

Characteristics and appearance

Sharply defining diagnostic categories in a domain that in reality consists of continua inevitably leads to patients not always fitting into the available boxes. There is therefore a need for a residual category: the atypical psychoses. Examples:

  • Persistent hallucinations without associated disorders
  • Postpartum psychoses (psychosis occurring following childbirth).

Some are inclined to place certain culture-bound syndromes in this category, often incorrectly.

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