4.1 Schizophrenia Spectrum and Other Psychotic Disorders

New DSM-5 takes a spectrum approach to schizophrenia and other psychotic disorders, with these disorders being defined by the presence of ONE or MORE of the following five domains:

• Delusions
• Hallucinations
• Disorganized thinking (or speech)
• Disorganized/abnormal motor behavior
• Negative symptoms

• Delusions
  • Fixed beliefs that are not amenable to change in light of conflicting evidence
    • Persecutory Delusions—belief that one is going to be harmed, harassed, etc. by an individual, organization, or some other group
    • Referential Delusions—belief that certain gestures, comments, environmental cues are directed at oneself
    • Grandiose Delusions—individual believes that he/she has exceptional abilities, wealth, or fame
    • Erotomanic Delusions—when an individual believes falsely that another person is in love with him/her
    • Nihilistic Delusions—one believes that a major catastrophe will occur
    • Somatic Delusions—focuses on preoccupations regarding health and organ functions
  • Are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences
  • Loss of body and mind are generally considered “bizarre”—one’s thoughts have been “removed” by some outside force (Thought Withdrawal) whereas thoughts that are put into one’s mind is called (Thought Insertion); as a final note, when one’s body or actions are being acted on or manipulated by some outside force, it is called (Delusions of Control)
• Hallucinations
  • Are perception-like experiences that occur without an external stimulus
  • They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control
  • Auditory Hallucinations are the most common in schizophrenia and other related disorders
    • Usually experienced as voices, familiar/unfamiliar, that are perceived as distinct from the individual’s own thoughts
    • Hallucinations that occur while falling asleep is called Hypnagogic, while waking up hallucinations are called Hypnopompic (Both NORMAL)
    • FYI, some hallucinations may be a normal part of religious experiences in certain cultures
• Disorganized Thinking Speech
  •  Formal Thought Disorder is typically inferred from the individual’s speech
  •  May switch from topic to topic and is also called Derailment or Loosed association
  •  Answer to questions may be obliquely related or complete or completely unrelated called Tangentially
  • RARELY, speech may be so severely disorganized that it is nearly incomprehensible and resembles receptive aphasia in its linguistic disorganization or incoherence or “word salad”
• Grossly Disorganized or Abnormal Motor Behavior (Catatonia)
  •  May manifest in a variety of ways–childlike “silliness” to unpredictable agitation
  •  May be noted in “goal-directed behavior or in difficulties in performing activities of daily living (ADLs)
    • Catatonic Behavior—is a marked decrease in reactivity to the environment; resistance to instruction (called Negativism); to maintaining a rigid, inappropriate/bizarre posture; to complete lack of verbal/motor responses (mutism/stupor)
    • Catatonic Excitement—Purposeless and excessive motor activity without obvious cause
    • Other features include—repeated stereotyped movements–starring, grimacing, mutism, and echoing of speech
• Negative Symptoms
  •  More prominent with the Schizophrenia diagnosis than with other psychotic disorders
  •  Two negative symptoms particularly prominent in schizophrenia:
    • Diminished Emotional Expression—reduction in the expression of emotions in the face; eye contact; intonation of speech; movement of the hand, head, and face that normally give an emotional emphasis to speech
    • Avolition—decrease in motivated self-initiated purposeful activities
      • Other negative symptoms include:
        • Alogia—diminished stimuli or a degradation in the recollection of pleasure previously experienced
        • Asociality—apparent lack of social interactions
      •  There is a Clinician-Rated Dimensions of Psychosis Symptom Severity (Page 743)

Treatment Interventions

When providing services to an individual diagnosed with Schizophrenia there is no best treatment. With that being said it will take a combination of antipsychotic medication, psychoeducation (therapy) and social support. Encouraging an individual to get involved with a “Drop in Center” for peer interactions will enhance their self esteem, social skills, communication while breaking the isolation and stereotypes. Currently, there are “Peer Mentor Program” available to make a referral to. A peer mentor is an individual who has a psychiatric diagnosis, who has learned how to navigate the mental health system, is recovering more importantly is committed to walking with an individual who just received a diagnosis. Peer Mentors are extremely valuable resource to utilize.