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Prevalence

Available evidence suggests variations in incidence across sociocultural settings. In the United States and other developed countries, the incidence is low, possibly fivefold less than that of Schizophrenia. In developing countries, the incidence is substantially higher, especially for the subtype "With Good Prognostic Features"; in some of these settings Schizophreniform Disorder may be as common as Schizophrenia.

Course

There is little available information on the course of Schizophreniform Disorder. Approximately one-third of individuals with an initial diagnosis of Schizophreniform Disorder (Provisional) recover within the 6-month period and receive Schizophreniform Disorder as their final diagnosis. Of the remaining two-thirds, the majority will progress to the diagnosis of Schizophrenia or Schizoaffective Disorder.

Familial Pattern

Few family studies have focused on Schizophreniform Disorder. Available evidence suggests that relatives of individuals with Schizophreniform Disorder have an increased risk for Schizophrenia.

Differential Diagnosis

Because the diagnostic criteria for Schizophrenia and Schizophreniform Disorder differ primarily in terms of duration of illness, the discussion of the differential diagnosis of Schizophrenia also applies to Schizophreniform Disorder. Schizophreniform Disorder differs from Brief Psychotic Disorder, which has a duration of less than 1 month.

Epidemiology

Incidence, course, prognosis, and other features
As with schizophrenia, the prevalence of schizophreniform disorder is equally distributed between the sexes, with peak onset between the ages of 18-24 years in men and ages 24-35 years in women. Unlike schizophrenia, in which prodromal symptoms may develop over several years, schizophreniform disorder requires, among other features, a rather rapid period from the onset of prodromal symptoms to the point at which all criteria for schizophrenia (except duration and deterioration) are met (within 6 mo).

According to the American Psychiatric Association, approximately two thirds of patients diagnosed with schizophreniform disorder progress to a diagnosis of schizophrenia. According to Benazzi et al, patients with a good prognosis tend to be retrospectively associated with the affective spectrum of diagnoses rather than the schizophrenic.

Patients with schizophreniform disorder and patients with schizophrenia share many anatomic and functional cortical deficits in neuropsychological, MRI, single-photon emission computed tomography (SPECT), and positron emission tomography (PET) studies. Studies have not yet elicited a consensus about whether ventricular enlargement is predictive of poor outcome in patients with a schizophreniform disorder.

According to Troisi et al, in some patients with a schizophreniform disorder, the presence of negative symptoms and poor eye contact appear to be prognostic of a poor outcome.

Treatment

In general, treatment aims to protect and stabilize the patient, to minimize the psychosocial consequences, and to resolve the target symptoms with minimal adverse effects. The patient who may be at risk of harming himself or herself or others requires hospitalization. This allows for complete diagnostic evaluation and helps to ensure the safety of the patient and others. A supportive environment with minimal stimulation is most helpful.

As improvement progresses, help with coping skills, problem-solving techniques, and psychoeducational approaches may be added for patients and their families. Patients may benefit from a structured intermediate environment, such as a day hospital, during the initial phases of returning to the community.

Psychotherapy
Virtually all psychotherapeutic treatment modalities used in the treatment of patients with schizophrenia may be helpful in treating patients with schizophreniform disorder. Insight-oriented therapy is not indicated in patients with schizophreniform disorder because they have limited ability to explore, and they may also be in denial.

Patients may experience a high degree of distress related to the onset of symptoms. Both supportive and educational approaches may help patients to manage feelings of turmoil or distress. Group psychotherapy may be helpful; however, patients with schizophreniform disorder who are concerned about their prognosis may become frightened in groups in which they are mixed with patients who have chronic schizophrenia. Thus, care must be taken when forming therapy groups.

Family and social-vocational therapies
The treatment of patients with schizophreniform disorder frequently involves working with family members and significant others. The family therapy strategies used in working with the families of patients with schizophrenia are highly appropriate for patients with schizophreniform disorder and their families.

In light of the variable course of schizophreniform disorder, brief treatment strategies with clear goals may initially be helpful, although treatment strategies must be flexible to allow for the transition to longer-term treatments for patients who progress to schizophrenia. Similarly, social-vocational function may be preserved in patients with schizophreniform disorder. However, in patients exhibiting impairments in these areas, rehabilitative strategies similar to those described for patients with schizophrenia are appropriate.

Pharmacotherapy
The pharmacotherapy for schizophreniform disorder is similar to that for schizophrenia.

At this time, atypical antipsychotics, such as risperidone, olanzapine, quetiapine, and ziprasidone, are commonly used. In November 2003, a new atypical antipsychotic drug, aripiprazole (Abilify), was approved by the US Food and Drug Administration. Aripiprazole has a novel mechanism of action because it is a partial agonist at the dopamine receptors, unlike its predecessors. Dosing strategies appear to be similar to recent approaches to treating patients with schizophrenia, which emphasize the use of minimal but effective doses. Sajatovic et al concluded in one study that both risperidone and quetiapine improved HAMD scores, although quetiapine demonstrated greater improvement when compared with risperidone in all patients.

Adequate treatment or prophylaxis of adverse extrapyramidal effects is critical to patient tolerance of neuroleptic treatment and to medication therapy compliance. Neuroleptic-resistant psychosis in patients with schizophreniform disorder may be managed through approaches similar to those used in patients with schizophrenia, including adjustment of the neuroleptic dose, addition of lithium, or addition of anticonvulsant agents and older typical antipsychotics.

Antidepressants may be helpful for mood disturbances associated with schizophreniform disorder, but care must be taken to monitor for possible exacerbations of psychotic symptoms.

According to Stromgren, electroconvulsive therapy has been helpful in treating brief reactive psychoses but is generally reserved for medication-resistant cases of schizophreniform disorder.

Compton suggested barriers to treatment following the first episode of psychosis including inadequate remission of paranoia, impaired insight, and involvement with the criminal justice system between the patient's discharge from the hospital and the patient's first outpatient appointment. Strong family support appeared to be an important facilitator of treatment engagement during the first several months of outpatient treatment. Various other potential barriers to treatment, such as involuntary status at the time of hospital discharge, are also considered.

Patient and family education
Efforts should be made to educate both the patients and their families about the early signs of relapse and the need for continuing treatment. Those approaches advance the overall aim of helping patients regain productive roles in society while reducing the risk of relapse. Families with a high degree of emotional expression are likely to cause additional stress to the patient and to increase the likelihood of relapse.

The patient's condition, the patient's family, and the patient's system of care are a few of the many factors that likely affect treatment engagement early in the course of schizophreniform disorder and schizophrenia. Clinicians should give special attention to these factors when caring for patients who experience their first episode.

Diagnostic criteria for 295.40 Schizophreniform Disorder

A. Criteria A, D, and E of Schizophrenia are met.

B. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as "Provisional.")

Specify if:

Without Good Prognostic Features

With Good Prognostic Features: as evidenced by two (or more) of the following:
(1) onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning
(2) confusion or perplexity at the height of the psychotic episode
(3) good premorbid social and occupational functioning
(4) absence of blunted or flat affect

Bibliography

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association; 2000.

Beiser M, Fleming JA, Iacono WG, Lin TY: Refining the diagnosis of schizophreniform disorder. Am J Psychiatry 1988 Jun; 145(6): 695-700[Medline].

Benazzi F, Mazzoli M, Rossi E: A follow-up and family study of DSM-III-R schizophreniform disorder with good prognostic features. Eur Arch Psychiatry Clin Neurosci 1992; 242(2-3): 119-21[Medline].

Compton MT: Barriers to initial outpatient treatment engagement following first hospitalization for a first episode of nonaffective psychosis: a descriptive case series. J Psychiatr Pract 2005 Jan; 11(1): 62-9[Medline].

Coryell W, Tsuang MT: Outcome after 40 years in DSM-III schizophreniform disorder. Arch Gen Psychiatry 1986 Apr; 43(4): 324-8[Medline].

Strakowski SM: Diagnostic validity of schizophreniform disorder. Am J Psychiatry 1994 Jun; 151(6): 815-24[Medline].