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Psychotic Disorders
Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you or that the TV is sending you secret messages. Hallucinations are false perceptions, such as hearing, seeing or feeling something that is not there.
What Are Delusions and Hallucinations?
Delusions
A delusion is a false belief or impression that is firmly held even though it is contradicted by reality and what is commonly held as true. There are delusions of paranoia, grandiose delusions, and somatic delusions.
People who are experiencing a delusion of paranoia might think that they are being followed when they are not or that secret messages are being sent only to them through media. Someone with a grandiose delusion will have an exaggerated sense of his or her importance. Somatic delusions are the belief that you have a terminal illness when you are healthy.
Hallucinations
A hallucination is a sensory perception in the absence of outside stimulus. That means seeing, hearing, feeling, or smelling something that isn't present. A person who is hallucinating might see things that don't exist or hear people talking when he or she is alone.
Delusions and hallucinations seem real to the person who is experiencing them.
Psychotic disorders are a collection of disorders in which psychosis predominates the symptom complex. Psychosis is defined as a gross impairment in reality testing. Specific psychotic symptoms include delusions, hallucinations, ideas of reference, and disorders of thought. Table 1-1 lists the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) classification of the psychotic disorders.
| Schizophrenia Schizophreniform Disorder Schizoaffective disorder |
Brief Psychotic Disorder Shared psychotic disorder Delusional Disorder |
It is important to understand that psychotic disorders are different from mood disorders with psychotic features. Patients can present with a severe episode of depression and have delusions or with a manic episode with delusions and hallucinations.
Definitions and Diagnoses
The term psychosis describes a disintegration of the thinking process, involving the inability to distinguish external reality from internal fantasy. The characteristic deficit in psychosis is the inability to differentiate between information that originates from the external world and information that originates from the inner world of the mind (such as distortions of normal thinking processes) or the brain (such as abnormal sensations and hallucinations).
Psychosis is a common feature of schizophrenia. Psychotic symptoms are often a feature of organic mental disorders, mood disorders, schizophreniform disorder, schizoaffective disorder, delusional (paranoid) disorder, brief reactive psychosis, induced psychotic disorder, and atypical psychosis.
Schizophrenia
A common and serious mental disorder characterized by loss of contact with reality (psychosis), hallucinations (false perceptions), delusions (false beliefs), abnormal thinking
Schizophrenia is best understood as a group of disorders with similar clinical profiles, invariably including thought disturbances in a clear sensorium and often with characteristic symptoms such as hallucinations, delusions, bizarre behavior, and deterioration in the general level of functioning.
Severe disturbances occur with relation to language and communication, content of thought, perceptions, affect, sense of self, volition, relationship to the external world, and motor behavior. Symptoms may include bizarre delusions, prominent hallucinations, incoherence, flat affect, avolition, and anhedonia. Functioning is impaired in interpersonal, academic, or occupational relations and self-care.
Schizophrenia can be divided into subtypes: 1) in the paranoid type, delusions or hallucinations predominate; 2) in the disorganized type, speech and behavior problems predominate; 3) in the catatonic type, catalepsy or stupor, extreme agitation, extreme negativism or mutism, peculiarities of voluntary movement or stereotyped movements predominate; 4) in the undifferentiated type, no single clinical presentation predominates; and 5) in the residual type, prominent psychotic symptoms no longer predominate. The diagnosis of schizophrenia requires a minimum of 6 months' duration of symptoms, with active psychotic symptoms for 1 week (unless successfully treated).
Psychotic Disorders
Clinicians generally divide the symptoms of schizophrenia into two types: positive and negative symptoms. Acute course schizophrenia is characterized by positive symptoms, such as hallucinations, delusions, excitement, and disorganized speech; motor manifestations such as agitated behavior or catatonia; relatively minor thought disturbances; and a positive response to neuroleptic medication.
Chronic course schizophrenia is characterized by negative symptoms, such as anhedonia, apathy, flat affect, social isolation, and socially deviant behavior; conspicuous thought disturbances; evidence of cerebral atrophy; and generally poor response to neuroleptics. In general, acute substance-induced psychotic symptoms tend to be positive symptoms. .
Schizophreniform disorder is a condition exhibiting the same symptoms of schizophrenia but marked by a sudden onset with resolution in 2 weeks to 6 months. Some patients exhibit a single psychotic episode only; others may have repeated episodes separated by varying durations of time.
Schizoaffective disorder is a condition that includes persistent delusions, auditory hallucinations, or formal thought disorder consistent with the acute phase of schizophrenia, but the condition is also frequently accompanied by prominent manic or depressive symptoms. Schizoaffective disorder is further divided into bipolar (history of mania) and unipolar (depression only) types. .
Delusional disorders are characterized by prominent well-organized delusions and by the relative absence of hallucinations; disorganized thought and behavior; and abnormal affect. The delusional disorders are divided into six types: persecutory, grandiose, erotomanic, jealous, somatic, and unspecified.
Brief reactive psychosis describes a condition in which an individual develops psychotic symptoms after being confronted by overwhelming stress. The onset of symptoms is abrupt, without the gradual symptom development often seen in schizophrenia or schizophreniform disorder, and the duration is brief (no longer than 1 month). .Induced psychotic disorder describes a disorder characterized by the uncritical acceptance by one person of the delusional beliefs of another. In other words, a dominant partner has a delusional psychosis that is believed and accepted by a passive partner.
Psychotic disorder facts
- Psychotic disorders include schizophrenia and a number of lesser-known disorders.
- The number of people who develop a psychotic disorder tends to vary depending on the country, age, and gender of the sufferer, as well as on the specific kind of disorder.
- There are genetic, biological, environmental, and psychological risk factors for developing a psychotic disorder.
- Usually with any psychotic disorder, the person's inner world and behavior have notably changed.
- When assessing a person suffering from psychotic symptoms, health-care professionals will take a careful history of the symptoms from the person and loved ones as well as conduct a medical evaluation, including necessary laboratory tests and a mental-health assessment.
- Most effective treatments for psychotic disorders are comprehensive, involving appropriate medications, mental-health education, and psychotherapy for the sufferer of psychosis and his or her loved ones. It will also include the involvement of community supportive services when needed.
- Prevention of psychosis primarily involves preventing or decreasing the impact of factors that put the person at risk for developing a psychotic disorder.
What are the different types of psychotic disorders?
Psychotic disorders are now referred to as schizophrenia spectrum and other psychotic disorders. In addition to the more commonly known mental disorders like schizophrenia, other mental disorders in this group include brief psychotic disorder, schizotypal personality disorder, delusional disorder, schizophreniform disorder, schizoaffective disorder, catatonia, substance/medication-induced psychotic disorder, psychosis due to a medical condition, other specified schizophrenia spectrum, unspecified schizophrenia spectrum, and other psychotic disorder. Besides catatonia, other catatonia-related disorders include catatonic disorder due to another medical condition, as well as unspecified catatonia. Women who recently had a baby (are in the postpartum state) may uncommonly develop postpartum psychosis. Also, mood disorders like major depressive disorder and bipolar disorder can become severe enough to result in psychotic symptoms like hallucinating or having delusions, also called psychotic features.
Schizophrenia and Other Psychotic Disorders
(for professionals)How common are psychotic disorders?
The percentage of people who suffer from any psychotic symptom at any one time (prevalence) varies greatly from country to country, from as little as 0.66% in Vietnam to 45.84% in Nepal. While the figure of one out of 100 people who qualify for the diagnosis of schizophrenia may sound low, that translates into about 3 million people in the United States alone who have schizophrenia. The first time a person has psychotic symptoms is usually between the ages of 18 and 24 years; related but less severe (prodromal) symptoms often start during the teenage years. Statistics for postpartum psychosis include that it occurs in one or two out of 1,000 births but increases greatly, up to one in seven mothers, in women who had postpartum psychosis in the past. Men are thought to develop psychotic disorders more often and at younger ages than women.
These patients do not have a primary psychotic disorder; rather, their psychosis is secondary to a mood disorder.
The diagnoses described below are among the most severely disabling of mental disorders. Disability is due in part to the extreme degree of social and occupational dysfunction associated with these disorders.
Schizophrenia
Schizophrenia is a disorder in which patients have psychotic symptoms and social and/or occupational dysfunction that persists for at least 6 months.
Schizophrenia affects I % of the population. The typical age of onset is the early 20s for men and the late 20s for women. Women are more likely to have a "first break" later in life; in fact, about one third of women have an onset of illness after age 30. Schizophrenia is diagnosed disproportionately among the lower socioeconomic classes; although theories exist for this finding, none have been substantiated.
The etiology of schizophrenia is unknown. There is a clear inheritable component, but familial incidence is sporadic and schizophrenia does occur in families with no history of the disease. Schizophrenia is widely believed to have a neurobiological basis. 
Delusional Disorder
Delusional disorder is characterized by nonbizarre delusions without other psychotic symptoms. It is rare, its course is chronic, and treatment is supportive.
This disorder is rare, with a prevalence of <0.05%. Generally, onset is in middle to late life; it affects women more often than men. Its course is chronic and unremitting.
The etiology is unknown. Often, psychosocial stressors appear to be etiologic, for example, following migration. In migration psychosis, the recently immigrated person develops persecutory delusions. Many patients with delusional disorder have a paranoid character premorbidly. Paranoid personality disorder has been found in families of patients with delusional disorder.
Prevalence
Various studies have noted that the lifetime prevalence rate for schizophrenia is roughly 1 percent among the general population (Africa and Schwartz, 1992). In the Epidemiologic Catchment Area (ECA) studies, the prevalence rate for schizophrenia and schizophreniform disorders combined were as follows: 1) 1-month prevalence rate: 0.7 percent; 2) 6-month prevalence rate: 0.9 percent; and 3) lifetime prevalence rate: 1.5 percent (Regier et al., 1988).
The ECA studies reported that the lifetime prevalence rate of schizophrenia was 1.5 percent, and the 6-month prevalence rate was 0. 8 percent. The lifetime and 6-month prevalence rates of schizophreniform disorder were both 0.1 percent (Regier et al., 1990).
Clinical observation of high rates of AOD use disorders among patients with schizophrenia were supported by the ECA studies. Among individuals identified as having a lifetime diagnosis of schizophrenia or schizophreniform disorder, 47 percent have met criteria for some form of an AOD use disorder. Indeed, the odds of having an AOD use disorder are 4.6 times greater for people with schizophrenia than the odds are for the rest of the population: the odds for alcohol use disorders are over three times higher, and the odds for other drug use disorders are six times higher (Regier et al., 1990).
One study noted that among patients with AOD use disorders, 7.4 percent had a lifetime diagnosis of schizophrenia; the 1-month prevalence rate was 4.0 percent (Ross et al., 1988), although other studies of persons in AOD abuse treatment found the prevalence of schizophrenia to be about the same as in the general population - about 1 percent (Rounsaville et al., 1991). While patients with AOD use disorders may experience acute episodic psychotic symptoms, few meet the diagnostic criteria for schizophrenia if AOD-induced symptoms are excluded.
Among severely mentally ill outpatient treatment populations, AOD use disorders are common; often more than 50 percent have AOD use disorders, depending upon the treatment setting. Among patients being treated for psychiatric problems in acute settings such as inpatient hospitals, combined psychiatric and AOD use disorders are also common.
Among patients with combined psychotic and AOD use disorders, bizarre behavior and communication generally prompt a mental health referral. Thus, people with psychotic disorders usually receive services through the mental health system and are rarely treated in the typical addiction treatment program.
