Defining Psychosis and Schizophrenia
Schizophrenia is a psychological disorder characterized by major disturbances in thought, perception, emotion, and behavior. About 1% of the population experiences schizophrenia in their lifetime, and usually the disorder is first diagnosed during early adulthood (early to mid-20s). Most people with schizophrenia experience significant difficulties in many day-to-day activities, such as holding a job, paying bills, caring for oneself (grooming and hygiene), and maintaining relationships with others. Schizophrenia is considered a disorder of psychosis, or one in which the person’s thoughts, perceptions, and behaviors are impaired to the point where they are not able to function normally in life. In informal terms, one who suffers from a psychotic disorder (that is, has a psychosis) is disconnected from the world in which most of us live.
Schizophrenia has a wide range of symptoms, and not all symptoms may be present in all forms of schizophrenia. The signs and symptoms of schizophrenia are usually divided into two categories: positive and negative. A third category of cognitive symptoms is also included in some descriptions of the disease. Both positive and negative symptoms are further characterized as motor, behavioral, and mood disturbances.
1. Positive Symptoms
Positive symptoms are disorders of commission, meaning they are something that individuals do or think. Examples include hallucinations, delusions, and bizarre or disorganized behavior. Positive symptoms can also be described as behavior that indicates a loss of contact with the external reality experienced by non-psychotic individuals. An example of a positive motor disturbance would be catatonic excitement, which is uncontrolled and aimless motor activity. Positive symptoms tend to be the easiest to recognize.2. Negative Symptoms
Negative symptoms are disorders of omission, meaning they are things that the individual does not do. Examples include alogia (lack of speech), flat affect (lack of emotional response), anhedonia (inability to experience pleasure), asociality (lack of interest in social contact), avolition (lack of motivation), and apathy (lack of interest). Some individuals will experience a catatonic stupor, or a state in which they are immobile and mute, yet conscious. They may exhibit waxy flexibility, where another person can move the patient’s limbs into postures and the patient will retain these postures, like a wax doll. In some cases, negative symptoms can be misinterpreted as depression or laziness.
Cognitive symptoms are the most harmful to the livelihood of the individual, as they prevent the individual from participating effectively in the workplace or in society. Cognitive symptoms are subtle differences in cognitive ability that are normally only discovered after neuropsychological tests are given. These include poor ability to absorb and act upon information (executive functioning), lack of attention, and an inability to utilize working memory.
Motor disturbances include disorders of mobility, activity, and volition. People with schizophrenia can exhibit too little (negative) or too much (positive) movement. In addition to catatonic stupor and catatonic excitement, examples of motor disturbances include stereotypy (repeated, non-goal directed movement such as rocking), mannerisms (normal, goal-directed activities that appear to have social significance, but are either odd in appearance or out of context, such as repeatedly running one’s hand through one’s hair or grimacing), mitgehen (moving a limb in response to slight pressure, despite being told to resist the pressure), ecopraxia (the imitation of the movements of another person), and automatic obedience (carrying out simple commands in a robot-like fashion).
2. Behavioral Disturbances
Disorders of behavior may involve deterioration of social functioning, such as social withdrawal, self-neglect, or neglect of environment. Behavioral disorders may also involve behaviors that are considered socially inappropriate, such as talking to oneself in public, obscene language, or inappropriate exposure. Substance abuse is another disorder of behavior; patients may abuse cigarettes, alcohol, or other substances. Substance abuse is associated with poor treatment compliance, and may be a form of self-medication.
Disorders of mood and affect include affective flattening, which is a reduced intensity of emotional expression and responsiveness that leaves patients indifferent and apathetic. Typically, one sees unchanging facial expression, decreased spontaneous movements, a lack of expressive gestures, poor eye contact, lack of vocal inflections, and slowed speech. Anhedonia, or the inability to experience pleasure, is also common, as is emotional emptiness. Patients may also exhibit inappropriate affect, such as laughing at a funeral.
Treatment
The primary treatment of schizophrenia is antipsychotic medications, often in combination with psychological and social supports. Hospitalization may occur for severe psychotic episodes either voluntarily or (if mental health legislation allows it) involuntarily. Community support services—such as drop-in centers, visits by members of a community mental-health team, supported employment, and support groups—are common. Some evidence indicates that regular exercise has a positive effect on the physical and mental health of those with schizophrenia. A number of psychosocial interventions may be useful in the treatment of schizophrenia, including family therapy, skills training, and psychosocial interventions for substance abuse. Family therapy or education, which addresses the whole family system of an individual, may reduce relapses and hospitalizations.
The Schizophrenia Spectrum
The spectrum of psychotic disorders includes schizophrenia, schizoaffective disorder, delusional disorder, and catatonia.
Schizophrenia is a psychological disorder characterized by major disturbances in thought, perception, emotion, and behavior. In order to be diagnosed with schizophrenia, according to the DSM-5, a person must exhibit both a psychotic episode and two additional symptoms for most of one month, and their symptoms must have a significant impact on social or occupational functioning for at least six months. The “two additional symptoms” can be delusions, hallucinations, disorganized speech, or a negative symptom or severely disorganized or catatonic behavior. If delusions or hallucinations or severe, only one symptom may be sufficient for diagnosis.
2. Schizoaffective Disorder
Schizoaffective disorder is characterized by abnormal thought processes and dysregulated emotions. A person with this disorder has features of both schizophrenia and a mood disorder (either bipolar disorder or depression) but does not strictly meet the diagnostic criteria for either. The bipolar subtype is distinguished by symptoms of mania, hypomania, or mixed episodes; the depressive subtype is distinguished by symptoms of depression only. Common symptoms of schizoaffective disorder include hallucinations, paranoid delusions, and disorganized speech and thinking.
The DSM-5 distinguishes schizoaffective disorder from psychotic depression or psychotic bipolar disorder by additionally requiring that a psychotic condition must last for at least two continuous weeks without mood symptoms (although a person may be mildly depressed during this time). Two episodes of psychosis (an increase from one episode in the DSM-IV) must be experienced in order for the person to qualify for this diagnosis.
4. Catatonia
Broadly speaking, catatonia is any condition of abnormal motor activity thought to be caused by a psychiatric disorder. For example, individuals with schizophrenia can demonstrate manic patterns of repetitious movement with no purpose, compulsively mimic the sounds or movements of others, or maintain the same posture for a long period of time without moving. In the DSM-5, catatonia is not recognized as its own disorder but rather is listed as a symptom of other psychiatric conditions, such as schizophrenia, bipolar disorder, post-traumatic stress disorder, and depression.
Definitions:
Delusions - False or irrational beliefs maintained despite clear evidence to the contrary.(2)
Psychotic disorders - Severe mental disorders in which a person experiences impairments in reality testing manifested through thought, emotional, or perceptual difficulties; no longer used as a diagnostic category after DSM-III.(2)
Schizoaffective disorder is characterized by abnormal thought processes and dysregulated emotions. A person with this disorder has features of both schizophrenia and a mood disorder (either bipolar disorder or depression) but does not strictly meet the diagnostic criteria for either. The bipolar subtype is distinguished by symptoms of mania, hypomania, or mixed episodes; the depressive subtype is distinguished by symptoms of depression only. Common symptoms of schizoaffective disorder include hallucinations, paranoid delusions, and disorganized speech and thinking.
The DSM-5 distinguishes schizoaffective disorder from psychotic depression or psychotic bipolar disorder by additionally requiring that a psychotic condition must last for at least two continuous weeks without mood symptoms (although a person may be mildly depressed during this time). Two episodes of psychosis (an increase from one episode in the DSM-IV) must be experienced in order for the person to qualify for this diagnosis.
3. Delusional Disorder
Delusional disorder is a psychiatric condition in which the person presents with delusions but no accompanying hallucinations, thought disorder, mood disorder, or significant flattening of affect. Apart from their delusions, people with delusional disorder may continue to socialize and function normally; their behavior does not stand out as odd or bizarre. However, their preoccupation with delusional ideas can disrupt their lives.
There are 7 subtypes of delusional disorder:
1) Erotomanic type (erotomania): Delusion that another person, often a prominent public figure, is in love with the individual.
2) Grandiose type: Delusion of inflated worth, power, knowledge, or identity.
3) Jealous type: Delusion that the individual’s sexual partner is unfaithful when such is not the case.
4) Persecutory type: Delusion that the person (or someone the person is close to) is being treated badly or malevolently.
5) Somatic type: Delusion that the person has some physical defect or medical condition.
6) Mixed type: Delusions with characteristics of more than one of the above types but with no single predominant theme.
7) Unspecified type: Delusions that cannot be clearly classified into any of the subcategories.
To be diagnosed with a delusional disorder, the individual’s delusions must last for at least one month and cannot be due to the effects of a drug, medication, or general medical condition. Delusional disorder cannot be diagnosed in an individual previously correctly diagnosed with schizophrenia. Auditory and visual hallucinations cannot be prominent, though olfactory or tactile hallucinations related to the content of the delusion may be present.
Delusional disorder is a psychiatric condition in which the person presents with delusions but no accompanying hallucinations, thought disorder, mood disorder, or significant flattening of affect. Apart from their delusions, people with delusional disorder may continue to socialize and function normally; their behavior does not stand out as odd or bizarre. However, their preoccupation with delusional ideas can disrupt their lives.
There are 7 subtypes of delusional disorder:
1) Erotomanic type (erotomania): Delusion that another person, often a prominent public figure, is in love with the individual.
2) Grandiose type: Delusion of inflated worth, power, knowledge, or identity.
3) Jealous type: Delusion that the individual’s sexual partner is unfaithful when such is not the case.
4) Persecutory type: Delusion that the person (or someone the person is close to) is being treated badly or malevolently.
5) Somatic type: Delusion that the person has some physical defect or medical condition.
6) Mixed type: Delusions with characteristics of more than one of the above types but with no single predominant theme.
7) Unspecified type: Delusions that cannot be clearly classified into any of the subcategories.
To be diagnosed with a delusional disorder, the individual’s delusions must last for at least one month and cannot be due to the effects of a drug, medication, or general medical condition. Delusional disorder cannot be diagnosed in an individual previously correctly diagnosed with schizophrenia. Auditory and visual hallucinations cannot be prominent, though olfactory or tactile hallucinations related to the content of the delusion may be present.
4. Catatonia
Broadly speaking, catatonia is any condition of abnormal motor activity thought to be caused by a psychiatric disorder. For example, individuals with schizophrenia can demonstrate manic patterns of repetitious movement with no purpose, compulsively mimic the sounds or movements of others, or maintain the same posture for a long period of time without moving. In the DSM-5, catatonia is not recognized as its own disorder but rather is listed as a symptom of other psychiatric conditions, such as schizophrenia, bipolar disorder, post-traumatic stress disorder, and depression.
Definitions:
Delusions - False or irrational beliefs maintained despite clear evidence to the contrary.(2)
Psychotic disorders - Severe mental disorders in which a person experiences impairments in reality testing manifested through thought, emotional, or perceptual difficulties; no longer used as a diagnostic category after DSM-III.(2)
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