Chapter 17. Other Psychotic Disorders

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Criteria A, D, and E of schizophrenia must be met.

2. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional.”

Specify if:

Without good prognostic features

With good prognostic features: as evidenced by two (or more) of the following:

1. onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning

2. confusion or perplexity at the height of the psychotic episode

3. good premorbid social and occupational functioning

4. absence of blunted or flat affect

(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000)

General Considerations

Epidemiology

Diagnostically, schizophreniform disorder is “positioned” in time between brief psychotic disorder (discussed later in this chapter), which lasts 1 month or less, and schizophrenia (see Chapter 16), which by definition continues beyond 6 months. Although many patients eventually will be shown to have schizophrenia, a small but significant number of patients with persisting psychotic disorders will show complete recovery of their illness. The proportion of recovery is likely to be small, although the exact percentage is unknown. Those who do show recovery typically exhibit characteristics known to predict better outcome in other diagnostic categories (e.g., acute onset, brief prodrome, lack of psychosocial deterioration, and prominent mood symptoms).

Etiology

Schizophreniform disorder is a heterogeneous category; therefore, in all likelihood, it has several distinct etiologies. Because most patients with this disorder will proceed on to meet diagnostic criteria for schizophrenia, the etiologies will be the same as for that condition, discussed in detail in Chapter 16. Some patients with this disorder appear to recover significantly and thus represent a manifestation that is distinct from typical schizophrenia.

Genetics

Because schizophreniform disorder is likely to be an etiologically heterogeneous disorder, genetic relationships are unclear. Those persons who proceed on to manifest typical schizophrenia show genetic predispositions that are similar to this condition. Those who recover completely may have increased family histories of both psychotic and affective disorders, especially bipolar disorder.

Clinical Findings

Signs & Symptoms

Patients with schizophreniform disorder exhibit symptoms consistent with Criterion A of schizophrenia (i.e., typically hallucinations; delusions; negative symptoms; disorganization of thought, speech, and behavior) that last between 1 and 6 months. Patients with these symptoms may proceed on to a typical pattern of schizophrenia and should be diagnosed as such if the symptoms are present for more than 6 months. However, others may proceed to complete or near-complete resolution of their symptoms. These patients generally have good premorbid function, acute onset (often after a stressor), and complete resolution without residual deficits in psychosocial function. In addition, mood symptoms tend to be more prominent and a family history of mood disorder is common in these patients.

Psychological Testing

Psychological testing will reveal a pattern of symptoms more typical of schizophrenia (see Chapter 16). These findings will include the common symptoms of thought disorganization, hallucinations, and delusions. However, overt cognitive impairment (including memory problems) is uncommon, and prominent mood symptoms may occur. Persons with schizophreniform disorder may demonstrate frontal cortical regional deficits such as impaired performance on the Wisconsin Card Sorting Test.

Laboratory Findings & Neuroimaging

Brain imaging studies may show the same results as those reported for schizophrenia. However, the differences often are less prominent, owing to the shorter duration of the condition. Alternatively, many patients do not show differences from normal controls, which may be associated with recovery. However, diagnostic imaging studies are not indicated.

A relative activation deficit in the inferior prefrontal region during performing the Wisconsin Card Sorting Test has been reported in both patients with schizophrenic and patients with schizophreniform disorder.

Course of Illness

Schizophreniform disorder often follows a course typical of schizophrenia. If symptoms are present for more than 6 months, psychological and social deterioration typically associated with schizophrenia may occur. First generation antipsychotics such as haloperidol reduce the symptoms of the illness but will not prevent deterioration if the symptoms are present for more than 6 months. The potential beneficial effects of newer, atypical antipsychotics (e.g., clozapine, risperidone, olanzapine, quetiapine) in preventing psychosocial deterioration or cognitive impairment has been hypothesized but not conclusively established.

Differential Diagnosis (Including Comorbid Conditions)

Although the major differential diagnoses are brief psychotic disorder and schizophrenia, the rapid onset of acute psychosis may be the most important diagnostic point. Attention should focus on the prior 6 months, the pattern of onset, and the presence of mood changes, alcohol and substance abuse, and other illness and prescriptive medications.

Treatment

The treatment of schizophreniform disorder is similar to that of schizophrenia (see Chapter 16).

Hospitalization is usually required in the acute stages of overt psychotic symptoms.

Psychopharmacologic Interventions

Antipsychotic drugs represent the mainstay of symptomatic management, and resolution of psychosis often is fairly rapid. It has been shown that patients with schizophreniform disorder respond to antipsychotic treatment much more rapidly than do patients with schizophrenia. Sedative agents, especially benzodiazepines, may be needed to manage acute agitation. Electroconvulsive therapy may be indicated for some patients.

Psychotherapeutic Interventions

Psychotherapy is usually needed to help patients integrate the psychotic experience. Psychosocial support and rehabilitation is critical with these patients to help reduce the deterioration in function more typical of schizophrenia. Therefore, rapid treatment of symptoms and social reintegration of the patient is important.

Other Interventions

After the resolution of acute symptoms, psychological, social, and occupational or educational treatment becomes the main focus of treatment. An acute schizophreniform psychotic episode represents a catastrophic event in the life of the patient, and psychotherapy is needed to help the patient understand the event and gain a sense of control over future episodes. A variety of issues should be discussed with the patient and his or her family or significant other: (1) the fundamental biological nature of the disorder; (2) the role of medication in controlling current and future symptoms, particularly the possible effect of symptom management on the evolution of the disorder; (3) the early-warning signs that indicate a return of psychosis; (4) the impact of the disturbance on the person's life and that of the family; (5) the need for gradual reintegration into work or school; and (6) the importance of future psychosocial management, including intensive case management or occupational or educational rehabilitation.

Prognosis

Most individuals with schizophreniform disorder are simply in the early stages of the development of more typical schizophrenia. The 6-month cutoff for the diagnosis of schizophreniform disorder acknowledges that although patients with typical schizophrenia symptoms sometimes show complete resolution, this seldom occurs when the symptoms have been present for 6 months or more. Almost all patients will then proceed to a course more consistent with schizophrenia, with persistent deterioration and impairment in psychosocial functioning. Exceptions to this rule are very rare.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. An uninterrupted period of illness during which, at some time, there is either a major depressive disorder, a manic episode, or a mixed episode concurrent with symptoms that meet Criterion A for schizophrenia.

Note: The major depressive episode must include Criterion A1: depressed mood.

1. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.

2. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.

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

Specifytype:

Bipolar type: if the disturbance includes a manic or a mixed episode (or a manic or a mixed episode and major depressive episodes)

Depressive type: if the disturbance only includes major depressive episodes

(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000)

General Considerations

Epidemiology

The lifetime prevalence of schizoaffective disorder is less than 1%. Schizoaffective disorder is characterized by prominent mood symptoms (mania or depression) occurring during the course of a chronic psychotic disorder. Phenomenologically, schizoaffective disorder holds the middle ground between mood disorders, especially psychotic mood disorders, and chronic psychotic conditions such as schizophrenia. The debate continues over whether schizoaffective disorder “belongs” to the spectrum of either schizophrenia or affective disorders, or represents a distinct category. Schizoaffective disorder likely represents a heterogeneous disorder with multiple distinct etiologies.

Etiology

Recent research indicates that there appear to be distinct etiologies and outcomes depending on whether the course of schizoaffective disorder is typified by episodes of bipolar-type cycling or simple depressive episodes in the absence of mania.

Genetics

In the bipolar variant, there is an increased proportion of family history of bipolar disorder (but not schizophrenia) and a better overall outcome. Although a family history of affective disorder is observed in the depressive variant, a history of psychotic disorder seems to be more common and outcome is poorer than in the bipolar form. Both variants usually have a better prognosis than does schizophrenia without prominent mood symptoms.

Clinical Findings

Signs & Symptoms

Patients with schizoaffective disorder exhibit symptoms consistent with DSM-IV-TR diagnostic Criterion A for schizophrenia. However, during the course of illness, there are superimposed episodes of depressive or manic symptoms. These patients would be diagnosed as having schizoaffective disorder, depressed or manic types, respectively. However, psychotic symptoms consistent with schizophrenia must be present for at least 2 weeks independently of the mania or depression syndromes.

Schizoaffective disorder, bipolar type, usually involves cycling of mania, depression, or mixed states in a way that is consistent with bipolar disorder. Similarly, patients with schizoaffective disorder, depressive type, may have repeated episodes of major depression, as in major depressive disorder. However, unlike depressive or bipolar disorders, there are consistent symptoms of schizophrenia in the absence of overt mood disorder. In schizoaffective disorder, depressive type, depressive episodes in which the patient meets full diagnostic criteria for major depression must be distinguished from the mood and negative symptoms associated with schizophrenia. For example, DSM-IV-TR criteria require the presence of persisting depressed mood for this diagnosis. Similarly, care should be taken to avoid misdiagnosing as mania agitation, hostility, insomnia, and other symptoms of an acute exacerbation of schizophrenia.

Psychological Testing

The results of psychological tests depend on the state of illness of a given patient. That is, although the typical results of schizophrenia usually are present (see Chapters 6, 16), characteristics of mood disorders also may be present. For example, psychological testing results will be consistent with depression or mania during corresponding episodes of illness. However, schizoaffective disorder, bipolar type, may be associated with less psychosocial and cognitive impairments than are schizophrenia or schizoaffective disorder, depressive type.

Course of Illness

Generally, persons with schizoaffective disorder have a course of illness that is intermediate between the mood disorders (with a relatively better prognosis) and schizophrenia (with marked residual psychosocial deterioration). However, distinctions also can be made for patients within the schizoaffective spectrum. Patients with schizoaffective disorder, bipolar type (i.e., those with a history of manic or mixed bipolar episode), have a course of illness that is more similar to bipolar disorder. These patients often have better functioning between acute episodes of illness than patients with either schizophrenia or schizoaffective disorder, depressive type. Patients with schizoaffective disorder, depressive type, tend to exhibit more typical schizophrenic symptoms and course, although when the disorder is managed properly, the prognosis may be better than typical schizophrenia without comorbid depression.

Differential Diagnosis (Including Comorbid Conditions)

Persons with schizophrenia are not immune to the occurrence of mood symptoms. When these features meet the diagnostic criteria for a mood disorder concurrently with features of schizophrenia, the diagnosis of schizoaffective disorder may be made. However, great care must be exercised in the evaluation in order to provide appropriate management of the disorder. For example, depressive symptoms not meeting full diagnostic criteria for a major depressive episode are common in schizophrenia and do not warrant a diagnosis of schizoaffective disorder per se. In fact, treatment of schizophrenia,  especially management with atypical antipsychotics, may reduce these symptoms in many patients without reliance on antidepressants. Alternatively, the negative symptoms of schizophrenia (e.g., apathy, withdrawal, avolition, blunted affect) may be confused with the symptoms of depression. Again, these symptoms generally are treated more effectively with atypical antipsychotics. Finally, the agitation, insomnia, and grandiose delusions of an acutely psychotic patient with schizophrenia sometimes can be confused with mania. However, a careful examination of the course of illness, prodromal symptoms, and acute presentation can be helpful in making the correct diagnosis. For example, the acutely agitated patient who presents for treatment after a period of progressive withdrawal, isolation, and bizarre behavior is unlikely to have mania. A good diagnostic rule of thumb is to evaluate the patient for the presence of current or past mood disorder by excluding the symptoms of schizophrenia, prior to confirming the diagnosis of schizoaffective disorder.

Psychotic mood disorders also may present with a confusing picture. DSM-IV-TR diagnostic criteria are written to aid the clinician in making this distinction. The presence of mood symptoms concurrent with psychosis, even symptoms that otherwise appear to be more like typical schizophrenia (i.e., bizarre behavior or disorganized speech) are not adequate to make the diagnosis of schizoaffective disorder. This condition is understood as representing a mood disorder superimposed on a course of schizophrenia. Therefore, the criteria require the symptoms of schizophrenia to be present for at least 2 weeks in the absence of prominent mood symptoms meeting diagnostic criteria for major depression, mania, or mixed state. A course consistent with dysthymia concurrent with schizophrenia does not constitute a diagnosis of schizophrenia.

Treatment

Psychopharmacologic Interventions

Once a definite diagnosis of schizoaffective disorder is made, treatment must take into consideration the necessity of managing both mood symptoms and psychotic symptoms (Table 17–1). Antipsychotics are required for the management of the psychotic features (see Chapter 17) and are typically used in these patients in acute manic states. Atypical antipsychotics are the first treatments of choice for several reasons. They can reduce both psychotic and more purely manic symptoms. They also exhibit mood stabilizing effects which are needed if cycling is present. Antidepressant drugs should be used as required in a manner similar to that discussed in Chapter 18 for the treatment of major depression. Alternatively, mood-stabilizing agents such as lithium, carbamazepine, or divalproex may be required adjunctively for the  treatment of mood cycling. The effectiveness of lamotrigine as an adjunctive antidepressant or mood stabilizer in this population is largely unknown. Finally, psychosocial management often is needed in much the same fashion as with schizophrenia or schizophreniform disorder to aid in social reintegration.

Psychotherapeutic Interventions

No single specific psychotherapeutic intervention has been recommended for schizoaffective disorder. However, patients may benefit from a combination of family therapy, social skills training, and cognitive rehabilitation.

Prognosis

Regardless of the diagnostic category (i.e., bipolar or depressive type), certain factors are associated with a poor outcome. They include insidious onset prior to the first psychotic episode; early onset of illness; poor or deteriorating premorbid functioning; the absence of a clear precipitating stressor; prominent negative symptoms in the prodromal, acute, or residual phases of illness; and a family history of schizophrenia. These factors are also associated with a poorer outcome in persons with schizophrenia without prominent mood symptoms.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration.

2. Criterion A for schizophrenia has never been met.

Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme.

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

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

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

Specify type (the following types are assigned based on the predominant delusional theme):

Erotomanic type: delusions that another person, usually of higher status, is in love with the individual

Grandiose type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person

Jealous type: delusions that the individual's sexual partner is unfaithful

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

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

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

(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000)

General Considerations

Epidemiology

The cause of delusional disorder is unknown. A very small proportion of the population (roughly 0.03%) experience persistent, relatively fixed delusions in the absence of the characteristic features of other psychotic disorders like schizophrenia.

Etiology

Etiologic theories about the development of delusional disorder abound, but systematic study is sparse. Early concepts of etiology focused on the denial and projection of unacceptable impulses. Hence, as examples,  homosexual attraction would be reformulated unconsciously to homosexual delusions or a belief in a love relationship with a famous person. Other theories  focus on projection of unacceptable sexual and aggressive drives, leading to paranoid fears of others. These and other psychodynamic theories have certain heuristic appeal, but little systematic study has been done to support these conjectures.

Genetics

Little is known about the genetics of delusional disorder. Family studies have suggested a decided lack of increased family history of psychotic or mood disorder.

Clinical Findings

Signs & Symptoms

Delusional disorder is characterized by nonbizarre delusions. Most often the delusional content appears possible, albeit far-fetched. For example, people with this condition may have fixed delusions that they are in an unrequited love relationship with a famous person or that they are being watched by the CIA, but not that their movements are being controlled by an external force. Persons with this condition may appear otherwise quite normal. They often hold jobs and may be married. The oddness and eccentricity of their beliefs and behavior may manifest itself only around the topic of the delusion.

The diagnosis of delusional disorder depends on the presence of nonbizarre delusions in the absence of meeting Criterion A for schizophrenia (see Chapter 16). Specifically, there should not be significant hallucinatory experiences, marked thought disorder, prominent negative symptoms, or psychosocial deterioration. Except for the behaviors associated with the delusions (e.g., delusional accusations of unfaithfulness in the spouse), the actions of the individual are not otherwise impaired. Although people with delusional disorder may have comorbid major depression or bipolar disorder, the delusions should be present at times when a mood disorder is not present and not just concurrently with an episode of depression or mania. Under these circumstances, however, care must be taken to distinguish this condition from schizoaffective disorder. Specifically, the symptoms must not meet criterion A of the schizophrenia diagnostic criteria.

Specific types of delusional disorder have distinguishing features. The most familiar is the so-called persecutory type, in which patients experience fixed (and often focal) paranoid delusions that other persons are intending to harm them in some way. These patients may believe that they are being watched or followed, or that malevolent parties are engaging in other persecutory or threatening behavior. The affected person will act in a way that is consistent with the content of the persecutory delusion but will otherwise be normal.

Another common variant is the jealous type. These patients exhibit delusional beliefs that their significant other is being unfaithful. As with the persecutory type, the plausible nature of the belief system may make it difficult to distinguish delusional beliefs from normal fears or real experiences. Patients with delusional disorder, jealous type, either have beliefs that cross the threshold of credibility or refuse to accept reasonable reassurances. For example, a 90-year-old man who believes that his 88-year-old wife is having sex regularly with young men may be suffering from delusional disorder.

In delusional disorder, erotomanic type (also referred to as de Clerambault syndrome), the delusion is that another person, usually someone who is famous or of higher social status, is in love with the affected individual. These beliefs may be highly elaborate, although plausibility is maintained. For example, a young woman with delusional disorder, erotomanic type, may travel around the country to attend the concerts of a famous performer. She may believe that the performer gives her secret signals during his concert that indicate his love. However, she also may believe that there is some external reason that he cannot express his love more directly, for example, because he is married, or has an ill mother, or some other reason. Persons with this condition seldom make direct contact with their paramour, although they may, occasionally, engage in more aggressive stalking behavior. Whenever the disorder occurs, it typically becomes the central focus of the person's life.

In the grandiose type of the disorder, the person experiences fixed, false beliefs of power (e.g., being the owner of a major corporation), money, identity (e.g., being the Prince of England), a special relationship with God (e.g., being Jesus Christ) or famous people, or some other distinguishing characteristic. These patients may be quietly psychotic but may come to treatment as a result of a contact with a government agency or other organization. For example, a person who believes that he is the President of the United States may be picked up trying to enter the grounds of the White House.

The somatic type of delusional disorder involves a fixed belief of some physical abnormality or characteristic. Distinguishing this disorder from simple hypochondriasis may be difficult and generally depends of the content of the belief and the degree to which the belief is held in spite of evidence to the contrary. People with somatoform disorders such as hypochondriasis or body dysmorphic disorder may have a fixed belief regarding a specific, serious, but plausible physical illness, such as cancer or AIDS. In hypochondriasis, these beliefs often relate to specific symptoms, such as pain, stiffness, or swelling. Patients with delusional disorder, somatic type, may have beliefs about other, more unusual conditions. These delusions may involve beliefs about contamination with toxic substances, infestations of insects or other vermin, foul body odors, malfunctions of specific body parts such as the liver or intestines, or other unusual content.

Finally, the mixed type of delusional disorder involves more than one of the types described above, without one taking prominence, and the unspecified type involves delusions that do not fall into one of the other categories. For example, the delusion of Capgras Syndrome is the belief that a familiar person has been replaced by an imposter.

Psychological Testing

Psychological testing will reveal the presence of the delusional psychotic material in these patients but, most often, little else. The cognitive impairments or social deterioration seen in schizophrenia are absent; if such impairments are present, the diagnosis of schizophrenia should be considered. Similarly, prominent mood symptoms might suggest a diagnosis of a psychotic mood disorder.

Laboratory Findings & Imaging

Neuroimaging data on delusional disorder are rare. Limited evidence indicates that persons with delusional disorder show reduced cortical gray matter and increased ventricular and sulcal size similar to that seen in schizophrenia. However, there has been little systemic study of this condition.

Course of Illness

Occasionally, patients with delusional disorder will go on to develop schizophrenia. This is an exception, though; most patients maintain the delusional diagnosis. About half of patients recover fully and about one-third improve significantly. Only about 20% maintain the delusion indefinitely.

Differential Diagnosis (Including Comorbid Conditions)

The differential diagnosis of delusional disorder encompasses broad categories of disorders. For example, delusional thinking may occur in patients with other psychotic disorders such as schizophrenia, schizoaffective disorder, mood disorders (bipolar disorder, manic or depressed type or major depression) with psychotic features, psychotic disorders due to a general medical condition, or substance-induced psychotic disorder. In delusional disorder, however, important features of those conditions will be absent. For example, the prominent hallucinations, negative symptoms, thought disorder, or social deterioration consistent with schizophrenia are not present. Similarly, mood symptoms, if present, are not prominent. The delusional thinking should not be accounted for by the presence of a medical condition or substance,  including substances of abuse. For example, a young patient with a history of stimulant abuse who exhibits paranoid ideation after a recent cocaine binge would not necessarily have delusional disorder.

A delusional diagnosis also may be easily confused with the obsessions of obsessive-compulsive disorder (OCD; see Chapter 21); however, in OCD the patient almost always has at least some insight into the exaggerated nature of the thoughts. Further, obsessions associated with OCD most often involve an inappropriate or exaggerated appraisal of a real threat. This could include a fear of contamination, loss of control of impulses, loss of important documents, and similar threats. When delusional disorder involves a fear of a specific threat, the fears are more typically paranoid or persecutory in nature.

Somatoform disorders such as hypochondriasis or somatization disorder are easily confused with delusional disorder, somatic type (see Chapter 22). As noted earlier, delusional disorder, somatic type, generally differs in both degree and type of belief. That is, in delusional disorder the beliefs are held tenaciously, and often will involve implausible content. Alternatively, people with body dysmorphic disorder often hold tenaciously to their preoccupation with a specific body part and are not easily dissuaded from the belief. In this case, the belief may seem like a delusion. The distinction is that the problem is perceptual, – i.e., is fixed on the appearance of a body part, and does not extend to other types of delusional beliefs.

Paranoid personality disorder also may be confused with delusional disorder (see Chapter 30). Two significant characteristics distinguish these disorders. In paranoid personality disorder, the hostility and paranoid thinking most often are generalized and affect multiple areas of the person's life. For example, the patient may be jealous of the spouse but also will exhibit hypersensitivity at work and in other areas. By contrast, the psychotic thoughts of delusional disorder usually are focused in a single area with remarkable preservation of other areas of thinking and functioning. Another feature distinguishing the disorders is the tenacity of the delusional belief. Persons with delusional disorder most often will maintain a stable but false belief system for long periods. Alternatively, the threatening beliefs of the person with paranoid personality disorder do not reach delusional proportions and often wax and wane in intensity.

Treatment

Psychopharmacologic Interventions

The treatment of delusional disorder relies heavily on the use of antipsychotic drugs, particularly the atypical antipsychotics; however, little systematic study has examined the effectiveness of this approach. Pharmacotherapy should be undertaken with caution: Patients with delusional disorder are convinced of the delusional beliefs and will usually resist medication management. Drug treatment should only be undertaken in the context of an ongoing therapeutic relationship in which there has been an effort to establish rapport, collaboration, and shared goals. For example, it is of little use to try to convince patients who have persecutory delusions that medicine will help them by changing how they think about the feared situation. Patients may be willing to take a drug that will calm the anxiety that has resulted from the persecution. Pimozide has been recommended for this condition; however, systematic study of this approach is lacking.

Psychotherapeutic Interventions

Individual supportive psychotherapy as well as family therapy may also be required.

Complications/Adverse Outcomes of Treatment

The main complication of delusional disorder has to do with whether the affected person acts on the delusion in some way. Most people with this disorder lead quiet, uneventful lives otherwise. However, a sudden, unexpected event may intervene, such as the stalking of a famous person. These events may lead to incarceration or involuntary hospitalization, which may surprise friends and coworkers. These actions are consistent with the content of the delusion. Unfortunately, treatment, at least in the short term, often is ineffective, leading to a repetition of the behaviors related to the false beliefs.

Prognosis

The prognosis of delusional disorder is good in most cases. About two third of patients recover or improve significantly; however, in about 20% of patients delusional symptoms persist and are usually treatment-resistant.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Presence of one or more of the following symptoms:

   1. delusions

   2. hallucinations

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

   4. grossly disorganized or catatonic behavior

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

1. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning.

2. The disturbance is not better accounted for by a mood disorder with psychotic features, schizoaffective disorder, or schizophrenia and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify if:

With marked stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture

Without marked stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture.

With postpartum onset: if onset within 4 weeks postpartum

(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000)

General Considerations

The emergence of transient psychotic symptoms, particularly after a severe psychological or social stressor such as a move or loss of a loved one, is not rare. Brief psychotic symptoms in the absence of a clear stressor are less common but also may occur. This disorder is generally associated with very acute onset and florid symptoms that decline rapidly even in the absence of the use of antipsychotic drugs. A diagnosis of brief psychotic disorder should be considered if a psychotic patient has a history of good premorbid functioning and an acute onset that resolves rapidly and completely in response to antipsychotic therapy.

Epidemiology

Reliable estimates of the frequency of this disorder are not available; however, an increased frequency is observed in populations that have experienced significant life stresses (e.g., immigrants, refugees, military recruits, and persons who have experienced a disaster such as an earthquake or hurricane). Therefore the frequency is going to depend on the population under study. Predisposing variables include comorbidity of personality disorder, substance use disorder, or dementia, or low socioeconomic status. Socioeconomic status may be associated with brief psychotic disorder in part because persons of lower social class may be at increased risk for major life stresses.

Etiology

A variety of stressors may occur prior to the onset of brief psychotic disorder. If the onset occurs within 4 weeks of giving birth, the specifier with postpartum onset is used. Many other stressors may predispose to the occurrence of this condition. For example, the disorder may occur after the death of a loved one, after a move to a new country (culture shock), during a natural disaster, or during combat or other military activity. A variety of factors are associated with the occurrence of brief psychotic disorder. They can be associated either with an increased likelihood of experiencing a stressor (e.g., lower socioeconomic status, refugee or immigrant status, presence in a war zone) or limitations in coping skills (e.g., persons with personality disorders, children or adolescents). However, the problem may also occur in people experiencing mild or no stressor and without predisposing characteristics.

Genetics

Family history relationships are unclear; however, there may be an increased risk of psychotic disorder (including brief psychotic episodes) or affective disorder in relatives of persons with this condition.

Clinical Findings

Signs & Symptoms

Psychotic symptoms occurring for 1 month or less with complete resolution constitute brief psychotic disorder. This condition occurs most often after a significant external stressor, although DSM-IV-TR allows the diagnosis without an obvious stress. The presentation is usually particularly florid. Patients can exhibit confusion, marked agitation or catatonia, emotional lability, and psychotic symptoms such as hallucinations or delusions. The symptoms may be so severe as to mimic the appearance of delirium.

Psychological Testing

Psychological testing has not been shown to be useful in adding to the diagnosis of brief psychotic disorder.

Laboratory Findings

There are no laboratory findings suggestive or supportive of brief psychotic disorder.

Course of Illness

Though by definition symptoms are brief and time-limited, recurrence of psychotic events often occurs, especially in the face of ongoing stressors or comorbid conditions such as personality disorder. When recurrence is frequent, long-term management with an antipsychotic (usually an atypical antipsychotic agent) may be indicated.

Differential Diagnosis (Including Comorbid Conditions)

The diagnosis of brief psychotic disorder is often difficult to make, and corroborative information from a family member or friend may be required to distinguish this problem from another psychotic disorder or cognitive disorder such as delirium.

A variety of disorders should be considered in the differential, including schizophrenia spectrum disorders (i.e., schizophreniform disorder, schizophrenia, or schizoaffective disorder), psychotic affective disorder, delusional disorder, personality disorder, substance use disorder (including withdrawal), delirium, psychotic disorder due to medical condition, or substance-induced psychotic disorder. Schizophrenia and related disorders (including delusional disorder) are distinguished by the duration of psychotic symptoms and impairments. Persons with brief psychotic disorder show complete resolution of their psychotic symptoms and impairments within the 30 days allotted for the diagnosis. The symptoms of persons with delusional disorder are more confined to the delusional content and are not as pervasive as that usually seen in brief psychotic disorder.

A diagnosis of psychotic affective disorder should be made in the presence of prominent mood symptoms meeting diagnostic criteria for mania or depression. This distinction may be difficult to make, especially in highly agitated or otherwise distressed patients. The mood, psychotic, and behavioral symptoms of affective psychosis rarely resolve completely within 30 days of initiation of treatment; therefore, if patients show complete return of baseline function within this time frame, a diagnosis of brief psychotic disorder should be considered, especially in the absence of a history of mood disorder.

Patients with personality disorder may present transient episodes of psychosis. This is particularly true of borderline personality disorder but may be seen in other disorders, including histrionic, schizotypal, or  obsessive-compulsive personality. These events almost always follow a significant stressor, especially an interpersonal stressful event. These occurrences may be very brief (i.e., less than 1 day) and would be included in the category of psychotic disorder not otherwise classified. However, if they occur for more than 1 day but less than 1 month, the patient should be given a diagnosis of brief psychotic disorder along with the personality disorder diagnosis. Finally, if the psychotic symptoms seem related to substance use or withdrawal or to a medical condition, the alternatives of substance use disorder (including substance-induced psychotic disorder) or psychotic disorder due to medical condition should be given diagnostic primacy.

Treatment

Treatment proceeds as with any other form of psychosis (Table 17–2). Hospitalization is usually required, and a reduction in sensory stimulation is helpful.

Psychopharmacologic Interventions

Antipsychotics and sedatives help to ameliorate the symptoms, especially by inducing sleep. Response to antipsychotic drug treatment is often rapid and complete. If complete resolution of psychotic symptoms occurs, the duration of treatment can be relatively brief i.e., one to three months. If brief psychotic disorder is recurrent, then longer-term treatment with an atypical antipsychotic should be considered.

Psychotherapeutic Interventions

Subsequent psychotherapeutic management should be aimed at three goals. The first goal of treatment is to help the person understand the nature of the problem, especially as it relates to the reaction to a specific stressor (if any). An acute onset of a major psychotic episode is a highly disruptive and disturbing event. Any person so affected needs to make sense of the experience. The second goal is rapid reintegration into the environment.

Other Interventions

Third, longer-term goals include the development of coping skills to help prevent subsequent episodes of illness. Because the problem may recur, it is important to help the patient and family recognize early prodromal signs (e.g., sleeplessness) of an impending episode.

Complications/Adverse Outcomes of Treatment

The principal complications of brief psychotic disorder have to do with the disruptions of social function, including employment, that may occur. As a result, rapid but stepwise reintegration is indicated in most patients. Careful attention should be paid to predisposing variables, including ongoing stressors (e.g., relationship stress, especially abuse) and comorbid disorders (e.g., comorbid personality or substance use disorders or medical conditions). Longer-term adverse outcomes may be more related to the outcome of these predisposing variables (especially personality disorder) than to the brief psychotic disorder per se. Some patients will never experience another psychotic event, whereas others will experience recurrences.

Prognosis

By definition, the short-term outcome of this disorder is good, though recurrence of symptoms is common, especially in the face of stressors or comorbid conditions. Long-term antipsychotic management may be indicated in some cases. Table 17–3 summarizes the favorable prognostic indicators of brief psychotic disorder.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. A delusion develops in the context of a close relationship with another person(s), who has an already-established delusion.

2. The delusion is similar in content to that of the person who already has the established delusion.

3. The disturbance is not better accounted for by another psychotic disorder (e.g., schizophrenia) or a mood disorder with psychotic features and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000)

General Considerations

Epidemiology

The exact frequency of shared psychotic disorder is not known. It may occur with greater frequency in certain groups or situations, especially with social isolation of the involved parties.

Etiology

The etiology of shared psychotic disorder is generally thought to be psychological. The dominant, psychotic person simply imposes the delusional belief on the submissive party.

Genetics

A genetic predisposition to idiopathic psychoses has been suggested as a possible risk factor for shared psychotic disorder.

Clinical Findings

Signs & Symptoms

Shared psychotic disorder, commonly referred to as folie à deux, occurs when a delusion develops in a person who has a close relationship with another person who already has a fixed delusion in the context of another psychotic illness such as schizophrenia or delusional disorder. Most often the person experiencing shared psychotic disorder is in a dependent or submissive position. This would include, as examples, the position of a dependent spouse or child of a psychotic person. Most cases involve members of a family, although it may occur in other situations (e.g., religious cults). Moreover, other factors such as old age, social isolation, low intelligence, sensory deprivation, cerebrovascular disease, and alcohol abuse are associated with shared psychotic disorder.

Course of Illness

In shared psychotic disorder, the patients must be separated for treatment purposes. In general, the healthier of the two will give up the delusional belief. The sicker of the two will maintain the false fixed belief.

Differential Diagnosis (Including Comorbid Conditions)

Differential diagnosis should consider the following: Delirium and dementia; alcohol-induced psychotic disorder; intoxications with sympathomimetics (incl. amphetamine, marijuana, L-Dopa); mood disorders; schizophrenia, and malingering and factitious disorders.

Treatment

Psychotherapeutic Interventions

In the most common situation, simple separation results in resolution of the delusional belief in the submissive member (folie imposée). Less commonly, the delusion fails to remit in either of the parties at separation (folie simultanée). In the rarest form, the dominant person induces a delusion in a second person, but that person goes on to develop his or her own additional delusional ideation (folie communiquée).

In the latter two conditions, antipsychotic drug therapy may be required to help reduce the psychosis of the submissive person. Table 17–4 summarizes the treatment options.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

Psychotic Disorder Due to a General Medical Condition

1. Prominent hallucinations or delusions.

2. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.

3. The disturbance is not better accounted for by another mental disorder.

4. The disturbance does not occur exclusively during the course of a delirium.

Substance-Induced Psychotic Disorder

1. Prominent hallucinations or delusions.

Note: Do not include hallucinations if the person has insight that they are substance induced.

1. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):

   1. the symptoms in Criterion A developed during, or within a month of, substance intoxication or withdrawal

   2. medication use is etiologically related to the disturbance

2. The disturbance is not better accounted for by a psychotic disorder that is not substance induced. Evidence that the symptoms are better accounted for by a psychotic disorder that is not substance induced might include the following: the symptoms precede the onset of the use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced psychotic disorder (e.g., a history of recurrent non-substance-related episodes).

3. The disturbance does not occur exclusively during the course of delirium.

(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000)

General Considerations

Many medical illnesses (Table 17–5) and drugs (Table 17–6) can induce psychotic symptoms. Other medical conditions, toxins, and drugs should be considered with any patient presenting with psychosis or with an exacerbation of a preexisting psychotic disorder. Psychotic conditions related to medical conditions are very common, especially in the hospital setting. Clinicians should be prepared to treat these conditions vigorously.

Clinical Findings

Signs & Symptoms

Hallucinations and delusions are common; however, the hallucinations of illness-related psychosis tend to be fairly specific to the underlying illness. For example, olfactory (smell) and gustatory (taste) hallucinations are associated with basal lesions of the brain or seizure disorders involving the temporal lobe or hippocampus. Alcohol or other sedative withdrawal may result in tactile (touch) hallucinations. Visual hallucinations may be reported in psychotic states induced by dopamine agonists, sympathomimetics, anticholinergics, or hallucinogenic drugs.

Treatment

Psychotherapeutic Interventions

The management of these disorders requires identification and aggressive management of the underlying illness or drug that has induced the psychosis (Table 17–7).

Psychopharmacologic Interventions

In addition, antipsychotics may be required to treat the psychotic symptoms acutely. Generally, elimination of the offending illness or drug will resolve the psychotic state. Drug treatment should be conservative and targeted to the offending symptoms, such as psychosis, insomnia, or agitation.

Prognosis

The long-term prognosis of these conditions relates to the course of the underlying illness. Psychosis in the face of medical conditions does not portend a favorable outcome in many patients, and may be seen in parallel with delirium, a poor prognostic feature. In addition, psychosis may recur if the fundamental medical disorder recurs.

Certain psychotic states cannot be classified into one of the foregoing categories of psychoses and are referred to as psychotic disorder NOS.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

This category includes psychotic symptomatology (i.e., delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate information to make a specific diagnosis or about which there is contradictory information, or disorders with psychotic symptoms that do not meet the criteria for any specific psychotic disorder.

Examples include:

1. Postpartum psychosis that does not meet criteria for mood disorder with psychotic features, brief psychotic disorder, psychotic disorder due to a general disorder

2. Psychotic symptoms that have lasted for less than 1 month but that have not yet remitted, so that the criteria for brief psychotic disorder are not met

3. Persistent auditory hallucinations in the absence of any other features

4. Persistent nonbizarre delusions with periods of overlapping mood episodes that have been present for a substantial portion of the delusional disturbance

5. Situations in which the clinician has concluded that a psychotic disorder is present, but is unable to determine whether it is primary, due to a general medical condition, or substance induced

(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000)

Several psychotic disorders have specific presentations or are contained within certain demographic groups. These disorders are widely recognized but are not accorded formal diagnostic status in DSM-IV-TR.

Capgras Syndrome (delusion of doubles)

This disorder represents a fixed belief that familiar persons have been replaced by identical imposters who behave identically to the original person.

Lycanthropy

This is a delusion that the person is a werewolf or other animal.

Frégoli Phenomenon

In this delusion, a persecutor (who usually is following the person) changes faces or makeup to avoid detection.

Cotard Syndrome (délire de négation)

A false perception of having lost everything, including money, status, strength, health, but also internal organs. This may be seen in schizophrenia or psychotic depression and responds to treatment of the underlying condition.

Autoscopic Psychosis

The main symptom is a visual hallucination of a transparent phantom of one's own body.

Koro

This disorder in males is characterized by a sudden belief that the penis is shrinking and may disappear into the abdomen. An associated feature may be the belief that when this occurs the person will die. A similar condition may be seen in women with fears of the loss of the genitals or breasts. Although this problem is seen more commonly in Asia, presentations in Western countries occur occasionally.

Amok

The amok syndrome consists of an abrupt onset of unprovoked and uncontrolled rage in which the affected person may run about savagely attacking and even killing  people and animals in his or her way. It is seen most often in Malayan natives but has been reported in other cultures. In some circumstances, this problem is observed in individuals with preexisting psychotic disorders.

Piblokto (Arctic Hysteria)

This disorder occurs among the Eskimos and is characterized by a sudden onset of screaming, crying, and tearing off of clothes. The affected person may then run or roll about in the snow. It usually resolves rapidly, and the person will usually have no memory of the event.

Windigo (Witigo)

Specific North American Indian tribes, including the Cree and Ojibwa, manifest this rare psychotic state.  People affected may believe that they are possessed by a demon or monster that murders and eats human flesh. Trivial symptoms including hunger or nausea may induce intense agitation because of a fear of transformation into the demon.