Schizophrenia Spectrum and Other Psychotic Disorders

Abstract

Psychotic disorders are often devastating to patients and their families. The symptoms can be both terrifying and disabling. While delusions and hallucinations are the often the most obvious manifestation of a psychotic disorder, a wide range of more subtle symptoms may also be present. Current antipsychotic treatments, while they can be effective, do not impact all aspects of psychotic illness and frequently carry a significant side effect burden. This chapter will provide an overview of the psychotic disorders, touching on their clinical presentation, neurobiology, and treatment.

Schizophrenia is arguably the worst disease affecting mankind (Editor, 1988).

Appendices

Appendix A: Tables with Possible Answers to Vignettes

Vignette 20.1.2

Facts	Hypotheses	Information needed	Learning issues
Unkempt appearance	A mood disorder seems less likely since she denies mood problems	What are the results of her toxicology screen?	What are delusions and hallucinations?
Denies mood problems	A substance-induced problem seems less likely since she denies use of alcohol and illicit substances (although must keep in mind that people do not necessarily admit to their substance use)	Could she be abusing a substance that would be missed by a routine toxicology screen?	How does a positive family history of schizophrenia affect the likelihood of a person having schizophrenia?
Denies drug and alcohol abuse		Does she have a family history of psychiatric illness?
Seems distracted but denies unusual perceptions	This could be the new onset of schizophrenia

Vignette 20.2.1: Kenneth Crabb

Facts	Hypotheses	Information needed	Learning issues
44-year-old man with decreased need for sleep	This presentation could be related to a general medical condition or to the abuse of an illicit substance	How are his vital signs? Anything abnormal on physical exam? Any abnormalities on laboratory studies? Is his toxicology screen consistent with his stated history?	What are other types of delusions?
Grandiosity	Since he was previous taking risperidone and divalproex, this may be a recurrence of some preexisting psychiatric illness		What are thought process disorders?
Jumbled thoughts
Rapid speech that is difficult to interrupt	His level of irritability and agitation increases his risk for violence	How does this episode compare with prior episodes?
Medication nonadherence		Has he ever been violent or attempted suicide?
Marijuana and alcohol use		What was his mental state and functioning like when on medications and not using drugs and alcohol?
Irritable mood

Vignette 20.2.3

Facts	Hypotheses	Information needed	Learning issues
Patient was admitted and started back on his previous medications	He meets criteria for schizoaffective disorder.	What other medications has he been tried on? What were his responses?	What are negative symptoms?
He improved but then began isolating and looked emotionless	His prior medication regimen allowed him to live independently, but he continues to be bothered by psychotic symptoms	Has he ever been tried on clozapine? If not, would he be willing to begin a trial?	What is the neurobiology of psychosis?
Family reported that he has multiple manic episodes before		Has he ever been on a long-acting injectible antipsychotic medication?	What is the role of genetics and the environment in the etiology of psychotic disorders?
Between manic episodes, he remains psychotic with delusions and hallucinations in spite of treatment		Has he been involved in any substance abuse treatment programs? Is he open to the idea?	What are the symptoms of schizophrenia and schizoaffective disorder?
He lived independently

Vignette 20.3.1: Sam Aloo

Facts	Hypotheses	Information needed	Learning issues
Patient presents with chief complaint of “skin worms”	It is unlikely that he contracted a parasite during his trip to Africa	Does he meet criteria for an anxiety disorder such as generalized anxiety disorder?	What are the symptoms of delusional disorder? What are the differential diagnoses?
Several months of having itchy sores on bilateral forearms and ventral thighs	Based on his prior history of excessive somatic concerns and the nature, location and symmetry of his skin lesions, this may be psychiatric in origin	Does he have other somatic concerns currently?
Cannot resist picking and scratching sores	A prior history of excessive somatic concerns does not rule out a subsequent general medical problem but raises suspicion that an atypical presentation could be psychiatric in origin	How does he function in his daily life?
History of recurrent somatic concerns		Why does he think his skin lesions are caused by worms?
History of travel to Africa		Has he had any unusual sensory perceptions?
He appears anxious		Has he had any delusions?

Vignette 20.3.2

Facts	Hypotheses	Information needed	Learning issues
Produces fibrous material that he says are dead worms	This is more than a simple anxiety or somatic disorder	How does he respond to the information that there are no parasites present?	When is it necessary to confront a person’s hallucinations and delusions, and how can it be done to preserve the therapeutic alliance?
He can feel them crawling under his skin and can see movement in his lesions	He is having frank hallucinations of a tactile and even visual nature	Is he flexible in his thinking? To what degree can he accept that there may be a psychiatric basis for his symptoms?	Does flexibility around delusional beliefs occur on a continuum?
Microscopic examination of “worms” reveals only fibrous tissue and no parasitic organism	He holds a fixed belief that he is infected by a worm-like parasite	How likely is it that he can comply with instructions to dress the lesions and leave them alone?

Vignette 20.3.3

Facts	Hypotheses	Information needed	Learning issues
His skin lesions continue to be problematic	He is frankly delusional and requires antipsychotic therapy	Will he adhere to antipsychotic medication therapy?	What factors should be considered in the treatment of Mr. Aloo?
		What kind of psychological issues will arise in the course of psychotherapy?
He produces another baggie of fibrous material	He meets criteria for delusional disorder	Can he stop picking at the lesions?	How can helping him work through his psychological conflicts through psychotherapy, even if seemingly unrelated to his somatic delusions, be helpful to his overall recovery?
He indicates a willingness to comply with antipsychotic therapy and psychotherapy	With his hallucinations, he could have schizophrenia	Are his hallucinations flowing from and intimately tied to his somatic delusions?

Vignette 20.3.4

Facts	Hypotheses	Information needed	Learning issues
He improves on risperidone therapy	His anxiety and dysphoric mood were directly related to his somatic delusion	Does he have side effects to the risperidone?	What is the role of pharmacotherapy and other treatment modalities in the treatment of psychotic disorders?
His skin lesions are healing	His obsessive skin picking was also directly related to his somatic delusion	Does he see the improvement?
His mood is improved as well

Appendix B: Answers to Review Questions

1. B, 2. A, 3. D, 4. C, 5. A, 6. B