Other Psychoses
Over the decades, these patients were often classified as having
atypical schizophrenia, good prognosis schizophrenia, remitting schizophrenia,
or cycloid psychosis. Inherent within these diag-noses was the implication that
they shared similarities to schizo-phrenia and also appeared to have a relatively
better course of illness. With the advent of effective treatment of bipolar
disor-der with lithium salts, some of these patients started responding to
lithium, and the term schizoaffective disorder gained further momentum and
evolved in the direction of bipolar disorder. Un-fortunately, this lack of
diagnostic clarity has plagued the diag-nosis of schizoaffective disorder such
that there is much that is unknown about the illness.
The diagnosis of schizoaffective disorder has undergone numer-ous
changes through the decades making it difficult to get reli-able epidemiology
information. When data was pooled together from various clinical studies,
approximately 2 to 29% of those patients diagnosed to have mental illness at
the time of the study were suffering from schizoaffective disorder with women
hav-ing a higher prevalence (Keck et al.,
2001). This could possibly be explained by a higher rate of depression in
women. Relatives of women suffering from schizoaffective disorder have a higher
rate of schizophrenia and depressive disorders compared with relatives of male
schizoaffective subjects. The estimated lifetime prevalence of schizoaffective
disorder is possibly in the range of 0.5 to 0.8%. In the inpatient settings of
New York State psychiat-ric hospitals, approximately 19% of 6000 patients had a
diagnosis of schizoaffective disorder (Levinson et al., 1999).
The depressive type of schizoaffective disorder appears to be more
common in older people while the bipolar type probably occurs more commonly in
younger adults. The higher prevalence of the disorder in women appears to occur
particularly amongst those who are married. As in schizophrenia, the age of
onset for women is later than that for men. Depression tends to occur more
commonly in women.
The etiology of schizoaffective disorder is unknown. There is a dearth
of data relating to this illness. Studies involving families of schizoaffective
probands suggest that they have significantly higher rates of relatives with
mood disorder than families of schizophre-nia probands. It is possible that
some of the same environmental theories that apply to schizophrenia and bipolar
disorder may also apply to schizoaffective disorder. It is most likely that
schizoaffec-tive disorder is a heterogeneous condition. Thus, depending on the
type of schizoaffective disorder studied an increased prevalence of either
schizophrenia or mood disorders may be found in their relatives. As a group,
patients with schizoaffective disorder have a prognosis intermediate between
mood disorders and schizophre-nia. Thus, on an average they have a better
course than those suf-fering from schizophrenia, respond to mood stabilizers
more often and tend to have a relatively nondeteriorating course.
Schizoaffective disorder criteria have evolved over the years and
undergone major changes. According to the DSM-IV, a patient with
schizoaffective disorder must have an uninterrupted period of illness during
which, at some time, they meet the diagnostic criteria for a major depressive
episode, manic episode, or a mixed episode concurrently with the diagnostic
criteria for the active phase of schizophrenia (criteria A for schizophrenia).
Addition-ally, “the patient must have had delusions or hallucinations for at
least 2 weeks in the absence of prominent mood disorder symp-toms” during the
same period of illness. The mood disorder symp-toms must be present for a
substantial part of the active and re-sidual psychotic period. The essential
features of schizoaffective disorder must occur within a single uninterrupted
period of illness where the “period of illness” refers to the period of active
or re-sidual symptoms of psychotic illness and this can last for years and
decades. The total duration of psychotic symptoms must be at least 1 month to
meet the criteria A for schizophrenia and thus, the minimum duration of a
schizoaffective episode is also 1 month.
The criteria for major depressive episode requires a mini-mum duration
of 2 weeks of either depressed mood or markedly diminished interest or
pleasure. As the symptoms of loss of pleas-ure or interest commonly occur in
nonaffective psychotic disor-ders, to meet the criteria for schizoaffective
disorder criteria A, the major depressive episode must include pervasive
depressed mood. Presence of markedly diminished interest or pleasure is not
sufficient to make a diagnosis as it is possible that these symptoms may occur
with other conditions too.
The DSM-IV diagnosis of schizoaffective disorder can be further
classified as schizoaffective disorder bipolar
type or schizoaffective disorder depressive
type. For a person to be clas-sified as having the bipolar subtype he/she
must have a disorder that includes a manic or mixed episode with or without a
history of major depressive episodes. Otherwise the person is classified as
having depressive subtype having had symptoms that meet the criteria for a
major depressive episode with no history of having had mania or mixed state.
The clinical signs and symptoms of schizoaffective disorder include all
the signs and symptoms of schizophrenia, and amanic episode and/or a major
depressive episode. The schizo-phrenia and mood symptoms may occur together or
in an al-ternate sequence. The clinical course can vary from one of
exacerbations and remissions to that of a long-term deteriora-tion. Presence of
mood-incongruent psychotic features – where the psychotic content of
hallucinations or delusions is not con-sistent with the prevailing mood – more
likely indicate a poor prognosis
The possible differential diagnosis consists of bipolar disorder with
psychotic features, major depressive disorder with psy-chotic features and
schizophrenia. Clearly, substance induced states and symptoms caused by
coexisting medical conditions should be carefully ruled out. All conditions
listed in differ-ential diagnosis of schizophrenia, bipolar disorder and major
depressive disorder should be considered including but not lim-ited to those
patients undergoing treatment with steroids, those abusing substances such as
PCP and medical conditions such as temporal lobe epilepsy. In circumstances
where there is ambi-guity, it may be prudent to delay making a final diagnosis
until the most acute symptoms of psychosis have subsided and time is allowed to
establish a course of illness and collect collateral information
Due to the evolving nature of the diagnosis and limited studies done
thus far much remains unknown. However, to the extent that this illness has
symptoms from both a major mood disorder and schizophrenia, theoretically one
can confer a relatively better prognosis then schizophrenia and a relatively
poorer prognosis then bipolar disorder, The following variables are harbingers
of a poor prognosis:
·
a poor premorbid history;
·
an insidious onset;
·
absence of precipitating factors;
·
a predominance of psychotic
symptoms, especially deficit or negative ones;
·
an early age of onset;
·
an unremitting course, and;
·
a family history of schizophrenia
The corollary would be that the opposite of each of these
charac-teristics would suggest a better prognosis. Interestingly, the pres-ence
or the absence of Schneiderian first-rank symptoms does not seem to predict the
course of illness. The incidence of suicide in patients with schizoaffective
disorder is at least 10%. Some data indicate that the suicidal behavior may be
more common in women then men.
In one study, 82% of those patients who were suffering from a first
episode of schizoaffective disorder, and had recov-ered, experienced psychotic
relapse within 5 years. These pa-tients had high rates of second and third
relapses despite careful monitoring. Medication discontinuations in first
episode patients who are stable for 1 year substantially increase relapse
risks. Aside from medication status, premorbid social adjustment was the only
predictor of relapse in their study. Poor adaptation to school and premorbid
social isolation predicted initial relapse independent of medication status.
Thus, like schizophrenia, the risk of relapse is diminished by antipsychotic
maintenance treat-ment (Robinson et al.,
1999).
\
With the shifting definitions of schizoaffective disorder, evaluat-ing
the treatment of schizoaffective disorder is not easy. Mood stabilizers,
antidepressants and antipsychotic medications clearly have a role in management
of these patients. The presenting symptoms, their duration and intensity, and
patient choices need to be incorporated into deciding what treatment(s) to
choose.
Atypical antipsychotic medications are reported to be more ef-fective
than the typical ones in the treatment of schizoaffective disorder. They appear
to have a more broad-spectrum effects then the typical agents. Optimizing
antipsychotic treatment, es-pecially with the novel agents, is more likely to
be effective than the routine use of adjunctive antidepressants or mood
stabilizers. However, when indicated, the use of antidepressants is well
sup-ported in schizoaffective patients who present with a full depres-sive
syndrome after stabilization of psychosis.
Olanzapine, ziprasidone and risperidone appear to be ef-fective against
symptoms of psychosis, mania and depression. Clozapine use may be beneficial in
the treatment of refractory schizoaffective disorder as it has both mood
stabilizing and an-tipsychotic properties, a substantial advantage.
Atypical antipsychotic medications are reported to be more ef-fective
than the typical ones in the treatment of schizoaffective disorder. They appear
to have a more broad-spectrum effects then the typical agents. Optimizing
antipsychotic treatment, es-pecially with the novel agents, is more likely to
be effective than the routine use of adjunctive antidepressants or mood
stabilizers. However, when indicated, the use of antidepressants is well
sup-ported in schizoaffective patients who present with a full depres-sive
syndrome after stabilization of psychosis.
Olanzapine, ziprasidone and risperidone appear to be ef-fective against
symptoms of psychosis, mania and depression. Clozapine use may be beneficial in
the treatment of refractory schizoaffective disorder as it has both mood
stabilizing and an-tipsychotic properties, a substantial advantage
A small number of studies suggest that valproic acid, lithium and
lamotrigine are effective in treating the manic symptoms associ-ated with
schizoaffective disorder, bipolar type.
Antidepressants The novel
antipsychotic agents are often ef-ficacious against depression in patients who
suffer from both de-pression and psychosis negating the need for routine use of
anti-depressants. However, there are patients who remain depressed even with
optimal antipsychotic and mood stabilizer treatment. SSRIs are widely used in
patients who present with schizoaffec-tive disorder with depression. If the
SSRIs and newer antidepres-sants do not show efficacy, tricyclic
antidepressants do have a role. Interestingly, chlorpromazine in combination with
amitriptyline was reported to be as effective as chlorpromazine alone. Many
studies suggest that addition of antidepressants helps in effective treatment
of depression in schizoaffective disorder. Occasion-ally, antidepressants may
worsen the course. For patients suffer-ing from depression where they are not
responding adequately and are at risk for suicide, ECT is an effective
alternative.
Psychosocial Treatment To the extent that schizoaffective
disorder shares symptoms with schizophrenia, most of the psy-chosocial
treatments used in the treatment of schizophrenia are likely to be useful in
the treatment of schizoaffective disorder. Specifically, patients benefit from
individual supportive therapy, family therapy, group therapy,
cognitive–behavioral therapy and social skills training. Many patients would be
suitable candidates for assertive community therapy (ACT). Depending on the
level of recovery, some of the patients may need rehabilitation services to
assist them with either developing skills for some form of em-ployment or
assistance to maintain a job. Family members benefit from support groups such
as NAMI or MDA groups.
Brief psychotic disorder is defined by DSM-IV-TR as a psy-chotic
disorder that lasts more than 1 day and less than a month Moreover, the
disorder may develop in response to severe psy-chosocial stressors or group of
stressors European and Scandina-vian countries have traditionally diagnosed
this type of psychosis as psychogenic
psychoses, reactive psychosis,
or brief reactive psychosis.
This illness is not uncommon, but, unfortunately, reliable esti-mates of
the incidence, prevalence, sex ratio and average age of onset are not
available. It is believed that this disorder is more common among young people
with occasional cases involving older people. This disorder may be seen more
commonly in pa-tients from low socioeconomic classes and in those with
person-ality disorders such as histrionic, paranoid, schizotypal, narcis-sistic
and borderline. Though immigrants and people who have experienced major
disasters are reported to be at a higher risk, well-controlled studies have
failed to show this.
The DSM-IV diagnostic criteria specify the presence of at least one
clear psychotic symptom lasting a minimum of 1 day to a maximum of 1 month.
Furthermore, DSM-IV allows the specifi-cation of two additional features: the
presence or the absence of one or more marked stressors and a postpartum onset.
DSM-IV describes a continuum of diagnosis for psychotic disorder based
primarily on duration of the symptoms. Once the duration crite-ria are met,
other conditions such as etiological medical illnesses and substance-induced
psychosis need to be excluded. In those cases where the duration of psychosis
lasts more than 1 month, appropriate diagnosis to be considered are other
psychotic condi-tions based on reevaluation of the clinical features, duration
of psychosis and presence of mood symptoms.
People
suffering from this disorder usually present with an acute onset, manifest at
least one major symptom of psychosis, and do not always include the entire
symptom constellation seen in schiz-ophrenia. Affective symptoms, confusion and
impaired attention may be more common in brief psychotic disorders than in
chronic psychotic conditions. Some of the characteristic symptoms include
emotional lability, outlandish behavior, screaming or muteness and impaired
memory for recent events. Some of the symptoms suggest a diagnosis of delirium and may
warrant a more complete medical workup. The symptom patterns include acute
paranoid reactions, reactive confusions, excitations and depressions
The precipitating stressors most commonly encountered are ma-jor life
events that would cause any person significant emotional turmoil. Such events
include the death of a close family member or severe accidents. Rarely, it
could be accumulation of many smaller stresses.
Although
the classical presentation may be short in duration and associated with
stressors, a thorough and careful evaluation is necessary. Additional
information is critical to rule out other ma-jor psychotic conditions as
temporal association of stressors to the acute manifestation of symptoms may be
coincidental and thus misleading. Other conditions to be ruled out include
psychotic disorder due to a general medical condition, substance-induced
psychosis, factitious disorder with predominantly psychological signs and symptoms, and malingering. Patients with epilepsy and
delirium may also present with similar symptoms. Additional conditions to be
considered are dissociative identity disorder and psychotic episodes associated
with borderline and schizotypal personality disorder that may last for less
than a day. signs and symptoms, and malingering. Patients with epilepsy and
delirium may also present with similar symptoms. Additional conditions to be
considered are dissociative identity disorder and psychotic episodes associated
with borderline and schizotypal personality disorder that may last for less
than a day.
As defined by DSM-IV, the duration of the disorder is less than 1 month.
Nonetheless, the development of such a significant psy-chiatric disorder may
indicate a patient’s mental vulnerability. An unknown percentage of patients
who are first classified as having brief psychotic disorder later display
chronic psychiatric syndromes such as schizophrenia and bipolar disorder.
Patients with brief psychotic disorders generally have good prognosis, and
European studies indicate that 50 to 80% of all patients have no further major
psychiatric problems.
The length of the acute and residual symptoms is often just a few days.
Occasionally, depressive symptoms follow the resolution of the psychosis.
Suicide is a concern during both the psychotic phase and the postpsychotic
depressive phase. Indi-cators of good prognosis are good premorbid adjustment,
few premorbid schizoid traits, severe precipitating stressors, sudden onset of
symptoms, confusion and perplexity during psychosis, little affective blunting,
short duration of symptoms and absence of family history of schizophrenia.
These patients may require short-term hospitalizations for a
comprehensive evaluation and safety. Antipsychotic drugs are often most useful
along with benzodiazepines. Long-term use of medication is often not necessary
and should be avoided. If maintenance medications are necessary, the diagnoses
may need to be revised. Clearly, the newer antipsychotic agents have a bet-ter
neurological side effect profile and would be preferred over the typical
agents.
Psychotherapy is necessary to help the person reintegrate the experience
of psychosis and possibly the precipitating trauma. Individual, family and
group therapies may be necessary in some individuals. Many patients need help
to cope with the loss of self-esteem and confidence.
Gabriel
Langfeldt (1939) suggested the term Schizophreniform Disorder in 1937 for a heterogeneous group of patients
character-ized by the similarity of their symptoms to those of schizophrenia
albeit with a good clinical outcome. Langfeldt observed that those patients
whose diagnosis was questionable as schizophrenia had a much better outcome
than those whose diagnosis was confirmed as schizophrenia; these patients were
thus classified as having schizo-phreniform psychosis. Langfeldt also noted
that these patients often had good premorbid adjustment, an abrupt onset of
symptoms, fre-quent presence of psychosocial stressor(s) and a good prognosis.
Several studies suggest that the relatives of patients with
schizo-phreniform psychosis are at a high risk of having psychiatric
dis-orders. The relatives of patients with schizophreniform psychosis are more
likely to have mood disorders than are the relatives of patients with
schizophrenia. In addition, the relatives of patients with schizophreniform
disorder are more likely to have a diagno-sis of a psychotic mood disorder than
are the relatives of patients with bipolar disorders.
Although brain-imaging studies suggest a similarity between
schizophreniform disorder and schizophrenia, one study of electrodermal
activity has indicated a difference. Patients with schizophrenia born during
the winter and spring months had hy-poresponsive skin conductances, but this
association was absent in patients with schizophreniform disorder. Though the
signifi-cance of this one study would be difficult to interpret, the results do
suggest caution in assuming similarity between patients with schizophrenia and
those with schizophreniform disorder. Data from a study of eye tracking in the
two groups also indicate that there are differences on some biological measures
between schiz-ophrenia and schizophreniform psychosis.
Schizophreniform disorder shares a majority of the DSM-IV-TR diagnostic
features with schizophrenia (see diagnostic criteria above) except the
following two criteria: 1) the total duration of the illness which includes the
prodrome, active, and residual phases is at least 1 month but less than 6
months in duration; and
though impairment in social and
occupational functioning may occur during the illness, it is not required or
necessary. Thus, the duration of more than 1 month eliminates brief psychotic
disorder as a possible diagnosis; if the illness lasts or has lasted for more
than 6 months, the diagnosis has to be reevaluated for other pos-sible
conditions including schizophrenia. Therefore, the diagnosis of
schizophreniform disorder is intermediate between brief psy-chotic disorder and
schizophrenia. Hence, those patients whose duration of episode lasted more than
a month and less than 6 months, and have recovered, would be diagnosed as
having schiz-ophreniform disorder. On the other hand those patients who have
not recovered from an episode, which is less than 6 months but more than one
month in duration, and are likely to have schizo-phrenia would be diagnosed as
having schizophreniform disorder until the 6 months criteria is met for
schizophrenia. The diagnosis of ‘provisional’ schizophreniform disorder is made
while the cli-nician monitors the evolving course of the illness, waits for the
symptoms to resolve, or when the clinician cannot obtain a reli-able history
from a patient about the duration of the symptoms.
The DSM-IV has specifiers for the presence or absence of good prognostic
features. These features include a rapid onset (within 4 weeks) of prominent
psychotic symptoms, presence of (psy-chogenic) confusion or perplexity at the
height of the psychotic episode, good premorbid adjustment as evidenced by
social and occupational functioning, and the absence of deficit symptoms such
as blunted or flat affect.
The clinical signs and symptoms and the Mental Status Exami-nation of
the patient with schizophreniform disorder are often similar to those with
schizophrenia, but the presence of affective symptoms usually predict a
favorable course. Alternatively, a flat or blunted affect may predict an
unfavorable course
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