o It can be other causes such as medical illnesses or

substance use
 Presence of mood symptoms/disorder?
 Deterioration of function

II. DOMAINS OF PSYCHOSIS

Psychotic Disorders A. DELUSIONS

Psychiatry  Must meet all three requirements:
YL7: 11.10 o False belief/s
 It's unshakable and inconsistent with the patient's
Dr. Shyne Marie Munar background
February 8, 2018 | 3:30PM – 5:30 PM o Firmly held
o Members of his group/culture do not share the same
GROUP 8: Arandia, Cruz, Dee, Dela Cuesta, Derada, Empedrado, Lacsamana, belief
Rafael, Ramos, Villarete

Types of Delusions
OUTLINE
OUTLINE ........................................................................................................... 1  Persecutory delusion
I. INTRODUCTION .......................................................................................... 1 o Most common type of delusion
A. PSYCHOSIS ............................................................................................ 1 o A delusion in which the central theme is that someone (or
B. DIAGNOSIS OF PSYCHOTIC DISORDERS.......................................... 1 someone to whom one is close) is being attacked,
II. DOMAINS OF PSYCHOSIS ........................................................................ 1
A. DELUSIONS ............................................................................................ 1
harassed, cheated, persecuted, mistreated, laughed at or
B. HALLUCINATIONS ................................................................................. 2 conspired against
C. DISORGANIZED THINKING ................................................................. 2  Paranoid delusion
D. DISORGANIZED BEHAVIOR ................................................................ 2 o Thoughts of being followed, watched, monitored, plotted
E. NEGATIVE SYMPTOMS .......................................................................... 2
against, harmed or killed
III. SCHIZOPHRENIC SPECTRUM ................................................................. 2
A. SCHIZOPHRENIA ................................................................................... 2  Referential
B. SCHIZOPHRENIFORM DISORDER ....................................................... 4 o A delusion in which events, objects or other persons in
D. BRIEF PSYCHOTIC DISORDER ............................................................ 5 one’s immediate environment are seen as having a
E. SCHIZOTYPAL PERSONALITY DISORDER .......................................... 5 particular and unusual significance
F. DELUSIONAL DISORDER ...................................................................... 5
G. SCHIZOAFFECTIVE DISORDER ........................................................... 5
 Grandiose
H. SUBSTANCE-INDUCED PSYCHOSIS ................................................... 6 o A delusion of inflated worth, power, knowledge, identity,
I. PSYCHOSIS DUE TO ANOTHER MEDICAL CONDITION .................... 6 or special relationship to a deity or famous person
IV. TREATMENT ............................................................................................... 6 o Exaggerated power, self-importance, possessions, titles
A. GOALS OF TREATMENT ........................................................................ 6
 Erotomania
B. BIOPSYCHOSOCIAL APPROACH .......................................................... 6
C. PHARMACOLOGIC THERAPY ................................................................ 6 o De Clerambault Syndrome
IMPORTANT NOTES ........................................................................................ 7 o A delusion that another person, usually of higher status,
REVIEW CENTER ............................................................................................. 8 is in love with the individual
FREEDOM SPACE ............................................................................................ 8  Infidelity/Jealousy
REFERENCES ................................................................................................... 8
APPENDIX......................................................................................................... 9
o Belief that one’s lover is unfaithful
o Pathological jealousy
I. INTRODUCTION  Nihilistic
o A delusion whose theme centers on the non-existence of
T/N: Dr. Munar has yet to ask Dr. Marinas if she can give her
self or parts of self, others, or the world. A person with
PPT. Dr. Munar told us to take the criteria from DSM-V and the
this type of delusion may have the false belief that the
rest from Kaplan.
world is ending.
 Somatic
A. PSYCHOSIS
o A delusion whose main content pertains to the
 State in which the person’s thoughts, affective response, appearance or functioning of one’s body
ability to recognize reality; and ability to communicate o Exaggerated beliefs of foul body odor, body shape,
and relate to others are sufficiently impaired defects or parasites in the skin/body
o Out of touch with the reality  Bizarre
 Psychotic disorders share one or more of the following 5 o A delusion that involves a phenomenon that the person’s
domains of psychosis: culture would regard as physically impossible
o Delusions o Absurd, fantastic, or weird
o Hallucinations  Delusion of Poverty
o Disorganized thinking o Ideas that one is bereft or deprived of all material
o Disorganized behavior possessions
o Negative symptoms  Delusion of Control
o A delusion in which one’s feelings, impulses, thoughts, or
B. DIAGNOSIS OF PSYCHOTIC DISORDERS actions are experienced as being controlled by external
 Psychosis or no psychosis forces rather than being under one’s own command
 Age of onset?  Folie à deux
o Important in classification o Delusion shared by two
 Duration of psychosis?  Folie à trois
o Duration of symptoms is also important in classification o Delusion shared by three
 Underlying causes?

11:10: Psychotic Disorders 1/9

B. HALLUCINATIONS
 False sensory perception occurring in the absence of any
relevant external stimuli
 Distinguished from illusions, in which an actual external
stimulus is misperceived or misinterpreted
Types of Hallucinations
 Auditory
o Most common in schizophrenia
o Involves sound, most commonly of voice, sometimes
perceived to be derogatory, commentary, command
 Visual
o May consist of formed images, such as people, or of
unformed images, such as flashes of light
o Usually seen in those with organic diseases
 Tactile
o A hallucination involving the perception of being touched
or of something being under one’s skin
o Usually seen in substance-abuse induced psychosis
 Olfactory
 Gustatory
C. DISORGANIZED THINKING
 Disturbance in flow and content of thought
 Illogical Thinking
o Erroneous connections, conclusions, or consequences
o Psychopathological only when it is marked and not
caused by cultural values or intellectual deficit
 Magical Thinking
o Belief that words or actions assume power, or one’s
thoughts cause or prevent events
 Though Broadcasting
o A delusion that one’s thoughts are being broadcasted to
the environment and can be perceived by others
 Thought Withdrawal
o A delusion that one’s thoughts are taken away by other
people or forces
 Thought Insertion
o A delusion that thoughts are implanted into one’s mind by
other people or forces
 Looseness of Association
o Unrelated and unconnected ideas shift from one subject
to another
 Perseveration
o Repetition of the same response to different stimuli, or
repetition of the same verbal response to different
questions
 Neologisms
o New words coined by the patient or old words with new
meanings
 Circumstantiality or Tangentiality
o Patient digresses into unnecessary details and
inappropriate thoughts before communicating the central
idea
 Circumstantiality – going around and around but
answers it eventually
 Tangentiality – kind of answers the question but never
answers it fully
 Clang Association
o Speech or words are associated by the sound of a word
rather than by its meaning
o Words have no logical connection
 Echolalia
o Psychopathological repeating of words or phrases;
repetitive; persistent
o Seen in severe types of schizophrenia
o They are usually difficult to interview because they just
repeat whatever you're saying
D. DISORGANIZED BEHAVIOR
 Don’t necessarily have to look disheveled
 Talking/whispering to self
 Abnormal gesturing
 Catatonia
o Marked decrease in reactivity to environment
o Rigid, inappropriate or bizarre posture generally
maintained for long periods of time
o Purposeless motor activity
 Mutism, stupor
 Hebephrenia
o Wild or silly behavior or mannerisms, inappropriate affect,
incoherence
E. NEGATIVE SYMPTOMS
 Diminished emotional expression/blunt affect
o Seen in face, eyes, speech, hands, body
 Avolition
o Decrease in motivation, interest, self-care
o They fail to care for themselves, they don't want to look
for work, and they just want to stay home and do nothing
 Alogia
o Diminished speech output
o May be in amount of spontaneous speech (poverty of
speech), or information (poverty of content)
 Anhedonia
o Decreased ability to experience pleasure from positive
stimuli
 Asociality
o Lack of interest in social interactions
III. SCHIZOPHRENIC SPECTRUM
A. SCHIZOPHRENIA
 Group of disorders with heterogeneous etiologies
 Signs and symptoms are variable and evolve through time
o Must be present for at least 6 months
 If it's less than 1 month, it's called brief psychotic
disorder
 If it's more than 1 month, but less than 6 months, it's
schizophreniform
 If there are associated manic episodes, it's called
schizoaffective
 Usually begins before 25 years old and persists
throughout life
 Affects all social classes
o 1% prevalence worldwide
 Diagnosis is based entirely on psychiatric history and
mental status exam
 No laboratory test for schizophrenia
o However, there are gene studies that are being done to
pinpoint specific genes that would make you predisposed
to have schizophrenia

11:10: Psychotic Disorders 2/9

A. Two (or more) of the following, each present for a significant
portion of time during a 1 -month period (or less if successfully
treated). At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression
or avolition).
B. For a significant portion of the time since the onset of the
disturbance, level of functioning in one or more major areas,
such as work, interpersonal relations, or self-care, is markedly
below the level achieved prior to the onset (or when the onset
is in childhood or adolescence, there is failure to achieve
expected level of interpersonal, academic, or occupational
functioning).
C. Continuous signs of the disturbance persist for at least 6
months. This 6-month period must include at least 1 month of
symptoms (or less if successfully treated) that meet Criterion A
(i.e., active-phase symptoms) and may include periods of
prodromal or residual symptoms. During these prodromal or
residual periods, the signs of the disturbance may be
manifested by only negative symptoms or by two or more
symptoms listed in Criterion A present in an attenuated form
(e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder
with psychotic features have been ruled out because either 1)
no major depressive or manic episodes have occurred
concurrently with the active-phase symptoms, or 2) if mood
episodes have occurred during active-phase symptoms, they
have been present for a minority of the total duration of the
active and residual periods of the illness.
E. The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or
another medical condition. F. If there is a history of autism
spectrum disorder or a communication disorder of childhood
onset, the additional diagnosis of schizophrenia is made only if
prominent delusions or hallucinations, in addition to the other
required symptoms of schizophrenia, are also present for at
least 1 month (or less if successfully treated).
(DSM-V, 2013)
o May be due to the following mechanisms
 Too much release of dopamine
 Too many dopamine receptors
 Hypersensitivity of dopamine receptors to dopamine
 Combination of these mechanisms
o Four dopamine pathways involved in schizophrenia
 Nigrostriatal
 Substantia nigra to striatum
 Involved in movement
 Responsible for extrapyramidal side effects (EPS)
 Projects into the basal ganglia
 Resembles the symptoms of Parkinson's disease
 Antipsychotics can cause potentially irreversible
disorders such as tardive dyskinesia, involuntary
movement of muscles, hyperactive movements in
the face and neck upon long-term use
 Mesolimbic
 Ventral tegmental area to nucleus accumbens
 Brainstem to the limbic part of the brain
 Motivations, emotions, reward
 Hyperactivity triggers positive symptoms
 Responsible for delusions and illusions when it's
overactive
 Mesocortical (mesofrontal)
 Ventral tegmental area to cortex
 Cognition and executive function, emotions and
affect
 Patients tend to be sluggish or lacks motivation
 Hypoactivity causes negative, positive and cognitive
symptoms of schizophrenia
 Tuberoinfundibular
 Hypothalamus to infundibulum (anterior pituitary)
 Influence prolactin release
 Blockade of D2 receptors cause increased PRL
 Causing amenorrhea, galactorrhea,
gynecomastia

Genetics
 Single largest risk factor
 Occur at an increased rate among biological relatives of
patients with schizophrenia
 Individuals who are genetically vulnerable to schizophrenia
do not inevitably develop schizophrenia
o Other factors (e.g. environment) must be involved in
determining schizophrenia outcome
o 1/3 actually have no family history of schizophrenia
 Many genetic markers are being identified that may
represent a predisposition to the illness
o No single gene has been identified yet but a cluster of Figure 1. Four Dopamine Pathways involved in Schizophrenia
genes
 Age of the father has a correlation with development of Table 1. Positive and negative symptoms of schizophrenia
schizophrenia POSITIVE NEGATIVE
o Those born from fathers >60 years old were vulnerable to
 Delusions  Flat or blunted affect
developing the disease
 Auditory hallucinations  Poverty of speech
 Thought disorders (alogia)
Biochemical hypothesis
 Inability to experience
 Glutamatergic Hypothesis pleasure (anhedonia)
o Hypofunctioning of glutamatergic signaling via NMDA  Lack of motivation
receptors (avolition)
 Dopamine Hypothesis
o Too much dopaminergic activity
 Most likely in the mesolimbic area
11:10: Psychotic Disorders 3/9
Neurotransmitters
 Norepinephrine
 Acetylcholine
o Decreased muscarinic and nicotinic receptors involved in
cognition
 Serotonin
o Serotonin excess cause both positive and negative
symptoms
 Glutamate
Neuropathology
 Neurochemical abnormalities in limbic system, basal
ganglia, cerebral cortex, thalamus, brainstem
 Loss of brain volume – reduced density of the axons,
dendrites, and synapses that mediate associative functions
of the brain
o The brain undergoes pruning during late adolescence
that is why schizophrenia is commonly seen in early
adulthood
o Studies have shown schizophrenics actually have lesser
dendrites and axons due to overpruning
 Lateral and third ventricular enlargement and some
reduction in cortical volume
Theories
 Psychoanalytic Theories
o Sigmund Freud
 Early developmental fixations (oral or anal stage),
defects in ego development (child rearing, oedipal
complex), ego disintegration, impaired ego functions
 Intrapsychic conflict arising from early fixations and the
ego defect
o Margaret Mahler
 Distortions in the reciprocal relationship between
the infant and the mother
 The person’s identity never becomes secure
o Harry Stack Sullivan
 Disturbance in interpersonal relatedness → sense of
unrelatedness → parataxic distortions
 Schizophrenia as an adaptive method to avoid panic,
terror and disintegration of the sense of self
 Learning Theories
o Child learns irrational reactions and ways of thinking
by imitating parents who have significant emotional
problems
o Schizophrenogenic mother
 Very restricting to child develops a different
understanding of the world and people leading to poor
interpersonal relationships
o Paradoxical, conflicting kind of communication based on
avoiding of punishment rather than reward-seeking
 For example, mother tells child that if he doesn’t do
this, she will leave him
 This kind of hate, anger and abandonment can lead to
a sense of helplessness
 Basically an issue of child-rearing
 Family Theories
o Theodore Lidz
 Schism (division) between the parents, one parent is
overly close to a child of the opposite gender
 Skewed (distorted) relationship between a child and
one parent involves a power struggle between parents
and resulting dominance of one parent
Outcomes
 20% have positive outcome
o Illness degenerates through time
11:10: Psychotic Disorders
 Most require constant daily living support
 Many are chronically ill
 Some have progressive deterioration
Five subtypes of schizophrenia
1. Paranoid
 Most common and has better prognosis
 Preoccupation with one or more delusions or frequent
auditory hallucinations
 Usually delusions of grandeur or persecution
2. Disorganized
 Formerly called hebephrenic
 Characterized by marked regression to primitive, disinhibited
and unorganized behavior and absence of symptoms of
catatonic type
 Laughing to self, gesturing, silly affect
3. Catatonic
 Marked disturbance in motor function
 Stupor, negativism, rigidity, excitement or posturing, and
waxy flexibility or catalepsy
 Person can be molded into a position that is then
maintained; when an examiner moves the person’s limb, the
limb feels as if it were made of wax
 Mutism is particularly common
4. Undifferentiated
 Clearly schizophrenic, cannot be easily fit into one type or
another
5. Residual
 Continuing evidence of the schizophrenic disturbance in the
absence of a complete set of active symptoms
 Emotional blunting, social withdrawal, eccentric behavior,
illogical thinking, and mild loosening of associations
(Kaplan and Sadock, 2015)
B. SCHIZOPHRENIFORM DISORDER
 Duration: 1 to 6 months
o Returns to baseline within 6 months
o May be episodic occurring after long periods of full
remission
 Acute, sudden onset and benign course associated with
mood symptoms and clouding of consciousness
 Cause is usually not known, possibly due to a stressor
 Has similarities to the episodic nature of mood disorders
 Lacks prodromal phase
o No slow decline in functioning or withdrawal
 Better outcome than schizophrenia
o No decline in social and occupational functioning after
episode
o After treatment, there will be no more psychotic episodes
4/9
A. Two (or more) of the following, each present for a significant
portion of time during a 1-month period (or less if successfully
treated). At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression
or avolition).
B. An episode of the disorder 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.”
C. Schizoaffective disorder and depressive or bipolar disorder
with psychotic features have been ruled out because either
1) no major depressive or manic episodes have occurred
concurrently with the active-phase symptoms, or 2) if mood
episodes have occurred during active-phase symptoms, they
have been present for a minority of the total duration of the
active and residual periods of the illness.
D. The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or
another medical condition.
(DSM-V, 2013)
D. BRIEF PSYCHOTIC DISORDER
 Sudden, acute, transient psychotic syndrome
 Duration more than 1 day but less than 1 month
 Remission is full
 Return to the premorbid level of functioning
 Not associated with a mood disorder, a substance-related
disorder, or a psychotic disorder caused by a general
medical condition
A. Presence of one (or more) of the following symptoms. At
least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.
Note: Do not include a symptom if it is a culturally sanctioned
response.
B. Duration of an episode of the disturbance is at least 1 day
but less than 1 month, with eventual full return to premorbid
level of functioning.
C. The disturbance is not better explained by major depressive
or bipolar disorder with psychotic features or another psychotic
disorder such as schizophrenia or catatonia, and is not
attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition.
(DSM-V, 2013)
E. SCHIZOTYPAL PERSONALITY DISORDER
 Diagnosed on the basis of the patients' peculiarities of
thinking, behavior, and appearance
 Unusual perceptions or perceptual distortions and have
eccentric behavior
 They have magical thinking, odd belief, odd thinking, and
odd speeches as well
o Vs. schizoid which doesn’t have magical thinking
 Most do not have friends because they find them odd
 Their affect may be inappropriate
 Very suspicious and eccentric
 Very reluctant is social situations
11:10: Psychotic Disorders
A. A pervasive pattern of social and interpersonal deficits
marked by acute discomfort with, and reduced capacity for,
close relationships as well as by cognitive or perceptual
distortions and eccentricities of behavior, beginning by early
adulthood and present in a variety of contexts, as indicated by
five (or more) of the following:
1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behavior and
is inconsistent with subcultural norms (e.g., superstitiousness,
belief in clairvoyance, telepathy, or “sixth sense”: in children
and adolescents, bizarre fantasies or preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (e.g., vague, circumstantial,
metaphorical, overelaborate, or stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree
relatives.
9. Excessive social anxiety that does not diminish with
familiarity and tends to be associated with paranoid fears
rather than negative judgments about self.
B. Does not occur exclusively during the course of
schizophrenia, a bipolar disorder or depressive disorder with
psychotic features, another psychotic disorder, or autism
spectrum disorder.
Note: If criteria are met prior to the onset of schizophrenia, add
“premorbid,” e.g., “schizotypal personality disorder
(premorbid).”
(DSM-V, 2013)
F. DELUSIONAL DISORDER
 Diagnosis is made when a person exhibits nonbizarre
delusion/s of at least 1-month duration that cannot be
attributed to other psychiatric disorders
o Nonbizarre – situations that can occur in real life
 Later onset than schizophrenia
 No other psychotic features but that single delusion
 These people are very difficult to treat because they are
very convinced that their delusion is real
A. The presence of one (or more) delusions with a duration of
1 month or longer.
B. Criterion A for schizophrenia has never been met. Note:
Hallucinations, if present, are not prominent and are related to
the delusional theme (e.g., the sensation of being infested with
insects associated with delusions of infestation).
C. Apart from the impact of the delusion(s) or its ramifications,
functioning is not markedly impaired, and behavior is not
obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these
have been brief relative to the duration of the delusional
periods.
E. The disturbance is not attributable to the physiological
effects of a substance or another medical condition and is not
better explained by another mental disorder, such as body
dysmorphic disorder or obsessive-compulsive disorder
(DSM-V, 2013)
G. SCHIZOAFFECTIVE DISORDER
 Used to be a wastebasket diagnosis in DSM-IV
 Has features of both schizophrenia and mood disorders
o Psychosis + major mood episode
o Usually, the psychotic episode persists and they become
depressed or have manic episodes
 Compared to bipolar mood disorder with psychosis
wherein once mood stabilizes, psychosis also
disappears
5/9
 Fit into one of the following categories: I. PSYCHOSIS DUE TO ANOTHER MEDICAL CONDITION
o Patients with schizophrenia with mood symptoms  Hallucinations can be present in delirium, associated with
o Patients with mood disorder who have symptoms of fluctuating levels of consciousness, confusion, impaired
schizophrenia cognitive abilities
o Patients with both mood disorder and schizophrenia  Delusions occur in the early course of dementia
o Patients with a third psychosis unrelated to schizophrenia  Psychosis secondary to a general medical condition, such
and mood disorder as:
o Patients whose disorder is on a continuum between o Severe thyroid disorders
schizophrenia and mood disorder o Typhoid fever
o Patients with some combination of the above o Malignancies
o Liver encephalopathy
A. An uninterrupted period of illness during which there is a o Metabolic encephalopathy
major mood episode (major depressive or manic) concurrent o Neurologic conditions (e.g. seizure and dementia)
with Criterion A of schizophrenia. Note: The major depressive o Other medical conditions
episode must include Criterion A 1: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the A. Prominent hallucinations or delusions.
absence of a major mood episode (depressive or manic) B. There is evidence from the history, physical examination, or
during the lifetime duration of the illness. laboratory findings that the disturbance is the direct
C. Symptoms that meet criteria for a major mood episode are pathophysiological consequence of another medical condition.
present for the majority of the total duration of the active and C. The disturbance is not better explained by another mental
residual portions of the illness. disorder.
D. The disturbance is not attributable to the effects of a D. The disturbance does not occur exclusively during the
substance (e.g., a drug of abuse, a medication) or another course of a delirium.
medical condition. E. The disturbance causes clinically significant distress or
(DSM-V, 2013)
impairment in social, occupational, or other important areas of
functioning.
H. SUBSTANCE-INDUCED PSYCHOSIS (DSM-V, 2013)
 Common substances are methamphetamine, cocaine,
cannabis, alcohol IV. TREATMENT
o Alcohol-induced psychosis is termed as delirium
tremens that usually happens on the 3rd day of A. GOALS OF TREATMENT
withdrawal
o Use of cannabis can actually precipitate schizophrenic  Goal in Psychiatry
episodes if you are predisposed or have genetic o Reduce suffering from mental disorders
vulnerability to it  Goals in treating psychotic disorders
o Methamphetamine users usually experience it during o Reduce symptoms
intoxication so they feel paranoid or feel like being o Improve patients’ functioning
watched or followed o Improve quality of life
 Once detoxicated, psychosis disappears o Normative role – live independently, attend school or
work, relate well to family, have friends, have intimate
relationships
A. Presence of one or both of the following symptoms:
1. Delusions.
B. BIOPSYCHOSOCIAL APPROACH
2. Hallucinations.
B. There is evidence from the history, physical examination, or  Biological Treatment
laboratory findings of both (1) and (2): o Antipsychotics which blocks dopamine
1. The symptoms in Criterion A developed during or soon after o Electroconvulsive therapy
substance intoxication or withdrawal or after exposure to a o No alcohol, no drugs
medication.  Can exacerbate psychotic symptoms
2. The involved substance/medication is capable of producing o Ensure good overall physical health
the symptoms in Criterion A.  Psychotherapies
C. The disturbance is not better explained by a psychotic  Social interventions
disorder that is not substance/ medication-induced. Such o Family meetings
evidence of an independent psychotic disorder could include o Support groups
the following: o Occupational therapy, vocational training, social skills
The symptoms preceded the onset of the training, milieu therapy (use of therapeutic communities)
substance/medication use; the symptoms persist for a  For occupational therapy, it has to be tailor fit to them
substantial period of time (e.g., about 1 month) after the  Social skills training is important because they don’t
cessation of acute withdrawal or severe intoxication: or there is really know how to properly communicate/relate with
other evidence of an independent non-substance/medication- people
induced psychotic disorder (e.g., a history of recurrent non-  Patients are admitted to hospital for milleu therapy so
substance/medication-related episodes). they learn from the people they live with
D. The disturbance does not occur exclusively during the
course of a delirium. C. PHARMACOLOGIC THERAPY
E. The disturbance causes clinically significant distress or  Typical antipsychotics (1 Generation)
st

impairment in social, occupational, or other important areas of o Inhibition of dopaminergic neurotransmission or high-
functioning. affinity antagonism of dopamine D2 receptors
(DSM-V, 2013) (dopamine receptor antagonists)

11:10: Psychotic Disorders 6/9

 o Chlorpromazine, Haloperidol, Levomepromazine, 5. Negative
Fluphenazine symptoms
o Adverse effects
 Neuroleptic Malignant Syndrome (NMS)
 Potentially fatal; a medical emergency
 Presents as extreme hyperthermia, severe muscular
rigidity and dystonia, akinesia, mutism, confusion, Schizoaffective 2 or more weeks Criteria A of
agitation, and increased pulse rate and blood in the absence of Schizophrenia +
pressure (BP) leading to cardiovascular collapse a major mood Manic/ Depressive
 Laboratory findings include increased white blood episode episode
cell (WBC) count, creatinine phosphokinase, liver Schizotypal PD beginning by early five (or more) of the
enzymes, plasma myoglobin, and myoglobinuria, adulthood following:
occasionally associated with renal failure 1. Ideas of reference
 Symptoms usually evolve over 24 to 72 hours and 2. Odd beliefs or
the untreated syndrome lasts 10 to 14 days magical thinking that
 Extrapyramidal symptoms influences behavior
 Akathisia – restlessness, jitteriness, pacing, rocking and is inconsistent
motions while sitting, rapid alternation of sitting and with subcultural
standing norms
 Dystonias – contractions of muscles that result in 3. Unusual
obviously abnormal movements or postures, perceptual
including oculogyric crises, tongue protrusion, experiences,
trismus, torticollis, laryngeal–pharyngeal dystonias, including bodily
and dystonic postures of the limbs and trunk illusions. 4. Odd
 Neuroleptic-induced Parkinsonism – muscle thinking and speech
stiffness (lead pipe rigidity), cogwheel rigidity, 5. Suspiciousness or
shuffling gait, stooped posture, and drooling paranoid ideation.
 Tardive Dyskinesia 6. Inappropriate or
 Adverse effect of long term antipsychotic constricted affect.
treatment usually seen with 10-20 year treatment 7. Behavior or
with typical antipsychotics appearance that is
 Abnormal involuntary movements of face, mouth, odd, eccentric, or
neck, trunk, limbs peculiar.
 Irreversible and happens through time with 8. Lack of close
chronic use of antipsychotics friends or confidants
 Treatment for EPS other than first-
 Biperiden degree relatives.
 Benztropine -not available in PH 9. Excessive social
 Trihexyphenidyl - not available in PH anxiety that does not
 Diphenhydramine diminish with
 Atypical antipsychotics (2 Generation)
nd
familiarity and tends
o Selective dopamine receptor antagonists to be associated
o Minimal neurologic side effects with paranoid fears
o More metabolic side effects rather than negative
 Hyperglycemia, hyperlipidemia, metabolic syndrome judgments about
 Monitoring is very essential self.
o Targets both negative and positive symptoms Schizophreniform Greater than 1 mo Same as Criteria A
o E.g. Olanzapine, Clozapine, Risperidone, Quetiapine, but less than 6 of Schizophrenia
Amisulpride, Aripiprazole, Ziprasidone, Asenapine, mos
Paliperidone Brief Psychotic Greater than 1 Presence of one (or
day but less than more) of the
IMPORTANT NOTES 1 mo following symptoms.
Doc said to focus on being able to differentiate the different At least one of these
kinds. Please check the Appendix for a guide to help must be (1), (2), or
differentiate the different disorders. (3):
1. Delusions.
Table 2. Psychotic Disorders Summary 2. Hallucinations.
Disorder Timing Symptoms 3. Disorganized
Criteria A speech (e.g.,
Schizophrenia Disturbance of 6 2 or more where at frequent derailment
mos w/ a 1 mo least 1 from (1-3) or incoherence).
period of symptom 1. Delusions. 4. Grossly
persistence 2. Hallucinations. disorganized or
3. Disorganized catatonic behavior.
speech Substance- The symptoms in Presence of one or
4. Grossly induced Criterion A both of the following
disorganized or developed during symptoms:
catatonic behavior. or soon after 1. Delusions.

11:10: Psychotic Disorders 7/9

 substance 2. Hallucinations. for 2 weeks then stopped altogether. She feels well now
intoxication or but is worried. What will you tell her?
withdrawal or after a) You’re glad she came c) She must take
exposure to a because her symptoms benzodiazepines
medication. could get worse. immediately or she could
Due to another direct Delusions and/or have a panic attack.
medical condition pathophysiological hallucinations b) What she had was merely d) She has schizophrenia
consequence of a brief psychotic episode and you must discuss
another medical and she should be fine. pharmacotherapy.
condition
Delusional At least 1 mo Non-bizare 5. Patient OP, 30, M has returned for a follow up. He has
disorder Delusions been diagnosed with Bipolar I disorder and said that
Criterion A for last month during his manic phase he was hearing
schizophrenia has voices telling him to buy everything in the grocery.
never been met Aside from that patient did not experience anything
else. Will you change his diagnosis?
REVIEW CENTER a) Yes. He has
schizoaffective disorder.
1. QW, 28, F, was referred to you for strange behavior –
walking around Ortigas chanting while dressed in all b) No. He only had
white which starts at exactly 3:33 am and ends at 4:44 psychotic features.
am. When asked about this she said that 3:33 is the
6. Patient XC, 55, unspecified gender, came in because
hour of evil and that her recent loss of work is due to
they believed that their partner has been cheating on
the spirits following. She has done chanting before in
them. Patient XC constantly checks the CCTV footage,
her previous residency in order to ward of evil spirits.
messages, and has even hired a private investigator.
Upon interview, patient shows blunting of affect and
While there is no evidence of cheating, Patient XC has
speaks in metaphors. When asked about the spirits she
accused their partner of cheating multiple times on
denies seeing or hearing them and instead only
them with non-transgender women. As the rotating
“knows” they’re present. Patient has severed ties with
clerk, the consultant asked you what kind of delusion
families and friends who refused to acknowledge her
patient XC is exhibiting.
beliefs. Which disorder is this most likely?
a) Paranoia c) Erotomania
a) Delusional disorder c) Brief Psychotic Disorder
b) Infidelity d) Persecution
b) Schizotypal PD d) Delirium Tremens
Answers: b, b, b, b, b
2. You were called to the ER to assist in the case of FG,
18, who jumped from the overpass because he believed
FREEDOM SPACE
that the military was chasing him. Upon interview of his
mother – who he has not spoken to in months – the
patient has confided to her 2 months PTC that he has
seen cameras following his every move and sometimes
hears a walkie talkie like sound and people paging to
each other. She says that he is unable to finish school
because he would always be late just in case someone
was waiting to ambush him. His mother also claimed
that the patient would hear footsteps following
himsince he was 15. Upon psych interview, the patient
is not oriented to person, time, and place and always
starts speaks in a sing-song voice. PMH is
unremarkable. Which disorder is this most likely?
a) Delirium Tremens c) Substance-induced
psychosis
b) Schizophrenia d) Delusional disorder

3. Patient JK, 19, M, came to the ER because he

believes that he was an angel of the lord and proceeded
to jump of from the balcony of a friend’s house. PTA
patient JK attended a party and ingested an unknown
substance. What is the most likely diagnosis?
a) Schizoaffective c) Brief Psychotic
b) Substance induced d) Schizotypal PD
4. Patient BN, 45, F was referred to you because she
previously couldn’t stop the feeling that ants were
crawling on her skin even when she has just showered,
when, she found out that her husband of 25 yrs has
been cheating on her with 6 different women and men.
She claims her symptoms started after that and lasted
th
19 century James Qua in his Chinese drug den
REFERENCES
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Arlington, VA:
American Psychiatric Publishing
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan &
Sadock's synopsis of psychiatry: Behavioral sciences/clinical
th
psychiatry (11 ed.). Philadelphia: Wolters Kluwer.

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 APPENDIX

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