A General Diagnostic Understanding: Schizophrenia and Related Psychotic Disorders

schizophreniaJen L’Insalata

Schizophrenia is a psychotic disorder characterized by the disruption of an individual’s sense of self and perception. Psychotic symptoms manifest in the form of auditory, visual, and sensational hallucinations, disordered or delusional thoughts, and disruptions in language and communication. An individual with schizophrenia is not always incoherent. Most individuals experience periods of active symptoms and symptom remission, while many experience at least one period of relapse (NIMH, 2009).

Schizophrenia is sometimes confused with having a split of multiple personality which are characteristic of another disorder. Diagnosing in an emergency room setting can be difficult as symptoms manifest differently in varying individuals. Involuntary hospitalization can only occur legally if a professional witnesses psychotic behavior which can take the form of the vocalization of delusional thoughts (NIMH, 2009).

295.90 (F20.9) Schizophrenia is characterized by delusions, hallucinations, disorganized speech that is easily derailed or incoherent, grossly disorganized or catatonic behavior, and negative symptoms including flat affect and diminished emotional expression. The symptoms must be severe enough to impact normal day to day function such as interpersonal relationships and self-care (APA, 2013). In an emergency room scenario it may be difficult to assess the impact of the symptoms on education and employment. It may be easier to visually assess the appearance of the individual to gather the extent of the symptoms on daily functionality. Schizophrenia can be distinguished from other psychotic disorders based on severity and length of duration of the symptoms. In schizophrenia the symptoms persist continuously for six months and meet the full diagnostic criteria for at least one month. If the duration and severity of the symptoms is less than the diagnostic criteria, a diagnosis of schizophrenipform disorder may be more appropriate. Additionally, if the active phase of psychosis includes depressive symptoms, a diagnosis of schizoaffective disorder may be warranted (APA, 2013).

Schizoaffective Disorder is similar to schizophrenia and symptoms include hallucinations, delusions, disorganized thought, and negative symptoms. In addition to the psychotic features present, individuals with schizoaffective disorder also exhibit features of depressive disorders and bipolar disorders. Coding for schizoaffective disorder is based on the mood episodes exhibited. 295.70 (F25.0) Schizoaffective Disorder, Bipolar type indicated there is a manic phase to the mood disturbances indicative of bipolar disorder. In 295.70 (F25.1) Schizoaffective Disorder, Depressive type, the individual experiences mood symptoms congruent with major depressive disorder (APA, 2013).

298.8 (F23) Brief Psychotic Disorder is characterized by the presence of delusions, hallucinations, disorganized speech and grossly disorganized or catatonic behavior. Symptoms last for at minimum, one day and at maximum, one month. Typically the onset is sudden and an individual goes from a non-psychotic to a psychotic state within two weeks. The differentiation between Brief psychotic disorder and other forms of psychotic disorder focuses on the length of time and onset of the symptoms. If the symptoms last longer that one month, the diagnosis of schizophrenipform disorder is more appropriate. Additionally, individuals who experience brief psychotic disorder do not meet the full DSM criteria for schizophrenia and show no disturbance in mood or affect. Individuals who experience brief psychotic disorder do not often show negative symptom that are common in schizophrenia. If mood congruent symptoms are present, schizoaffective disorder is a more appropriate diagnosis (APA, 2013).

The exact cause of schizophrenia is still unknown. It is believed that there is genetic, biological, and environmental links that correspond with the disorder and provide risk factors. Schizophrenia shows a genetic component and runs within families. Having a first degree relative with schizophrenia increases a person’s likelihood to develop the disorder themselves. Environmental factors such as exposure to prenatal viruses, malnutrition, and complications during birth also increase the risk of schizophrenia (NIMH, 2009). According to the diathesis stress model, individuals inherit a high or low genetic risk for schizophrenia. Varying psychosocial factors throughout the lifespan such as stressors and experiences influence the trajectory and development of the disorder (U.S. Department of Health and Human Services, 1999).

Several genes have been linked to schizophrenia and individuals with schizophrenia have a higher rate of gene mutation than healthy individuals. Brain physiology also differs in individuals with schizophrenia. Ventricles in the center of the brain are often larger in schizophrenic patients and individuals have decreased amounts of gray matter than healthy individuals. Genes that code for the chemicals associated with the development of higher brain function, neurotransmitters such as dopamine and glutamine are also effected which cause changes to the neuropathways that develop during puberty (NIMH, 2009).

Individuals with schizophrenia who receive treatment have a better outcome than individuals who do not. One halt to two thirds of individuals who receive treatment recover or show significant improvement over time (U.S. Department of Health and Human Services, 1999). Treatment for schizophrenia includes both psycho-pharmisudical and psychotherapeutic interventions that focus on eliminating the symptoms and developing coping strategies.

During the 1950’s antipsychotics were developed to treat schizophrenic symptoms. This first generation of antipsychotics consisted of medications including Chlorpromazine (Thorazine), Haloperidol (Haldol), Perphenazine (Etrafon, Trilafon), Fluphenazine (Prolixin), and Clozapine (Clozaril). Each individual responds to treatment differently, however Clozapine appeared to be most effective in the most varied cases. Clozapine also had a side effect that reduced white blood cell count requiring patients using the medication to receive blood screening every two weeks (NIMH, 2009).

During the 1990’s a second generation of antipsychotics were developed that had reduces side-effects. These include Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon), Aripiprazole (Abilify), Paliperidone (Invega); which are more commonly prescribed today. Side effects to antipsychotics may include drowsiness, dizziness, blurred vision, rapid heartbeat, sensitivity to the sun, and skin rashes. In women, menstrual problems may occur. Additional side effects may be physical in nature and long term use of antipsychotics may cause loss of neuromuscular control. Once a compatible antipsychotic is found patients may see improvements in as little a few days, with an overall reduction in psychotic symptoms in as little as six weeks (NIMH, 2009).

In addition to pharmisudical treatment, psychotherapy is important to an individual’s recovery.  Therapy provides prosocial, interpersonal, vocational skills, and education that helps prevent relapse of symptoms. Family and community based therapy helps to build a support system that also helps improve the individual’s prognosis. Psychosocial and Cognitive Behavioral Therapy address the disruptive thoughts and perceptions that are symptomatic of schizophrenia. CBT helps develop coping skills that allow the individual to test the legitimacy of their delusions or hallucinations and implement healthy behavioral alternative to actin on such thoughts. Prosocial components address areas of daily self-care, occupational, and educational skills that help schizophrenic patients live healthy and functioning lives (U.S. Department of Health and Human Services, 1999, & NIMH, 2009).

Schizophrenia effects men and woman and displays cultural equality, however not all symptoms manifest the same. Misdiagnosis can occur if the culture to which a patient differs from that of the diagnosing clinician.  Many cultural sub groups participate in religious experiences where hearing voices or seeing vision is acceptable. In other cultures, affect and avoidance can be misinterpreted as paranoia or other negative symptoms. It is important to understand the culture from which an individual comes from to determine if the symptoms are due to psychosis or cultural misinterpretation (U.S. Department of Health and Human Services, 1999, & NIMH, 2009).

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. ISBN: 9780890425558.

National Institute of Mental Health. (2009). Schizophrenia. Retrieved from http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Retrieved from http://profiles.nlm.nih.gov/ps/access/NNBBHS.pdf

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