Classification of psychotic
The following is a list of schizophrenia and the related conditions of it
2. schizophreniform disorders
3. schizoaffective disorders
4. delusional disorders
5. brief psychotic disorders
6. shared psychotic disorders
7. substance induced psychoses
8. psychoses due to medical conditions
9. psychoses not otherwise specified (or classified)
is one of the most common severe mental illnesses and
is reported to have a lifetime incidence of 1%.
Schizophrenia is typically diagnosed before age 25 and
is diagnosed equally in men and women .
When it is diagnosed after age 45, it is considered late
The usual age of onset is the mid-twenties but can be
older, particularly in women.
Schizophrenia occurs worldwide in all ethnic groups.
Etiology of schizophrenia
The cause of this disorder is unknown until now, but the huge
studies that had been made about this subject in the last
century led to many theories:
However, it had been found that schizophrenia has biological
basis plus environmental factors "social and psychological
so schizophrenia is " biopsychosocial in origin" which means
that the biological causes are essential and must be present
as a basis and the environmental causes either precipitate or
maintain the disorder.
In fact, life changes like marriage, entrance into college,
going into a new house have a profound effect in precipitating
the psychotic disorder or maintain it.
Hereditary causes (Genetics): Three types of studies had been made on schizophrenics to confirm that the
disorder has a genetic basis (i. e. that is transmitted from parents to children by genetic factors) and that
A. Family studies
B. Twin studies
C. Adopted children studies
So in details:
A. In family studies, it had been found that the :
2nd and 3rd degree relatives have a 2.5% more possibility than the general population to be affected by
the disorder (5 in every 200 are affected).
In the children of one schizophrenic parent have 12% more possibility.
If both parents are schizophrenics, the 25% will be affected of their children (i.e. if the schizophrenic
parents have 4 children then one of them will be affected).
• It's not clear if the presence of one schizophrenic patient in the family will affect the other members of
the family or relative by a genetic basis or environmental one because the presence of this patient may
have an effect on rearing up of the other members of the family and relatives
The twins are either identical (the twin have the same genetic
material) or non identical (the twins have different genetic
In fact, the study of identical twins gives more accurate
information about the genetic role towards this disorder.
• It has been that 45% of the identical twins share in the
disorder (if patiens have schizophrena the 45 of their
identical twins have also the disease)
• While only 12% of non identical twins share the
disease and in this condition, the two have a weaker link.
So genetics have a role in etiology of the disease, but the
environmental factors must be present to complete the final
picture of schizophrenia i.e. genetic has no 100% role in
It had been found that children of schizophrenia
parents (we depend mainly on the mother because the
father may be not known) if they are adopted and taken
into live in a place which different and far from their
parents, they will acquire schizophrenia in their
The study of adopt children confirms the genetic basis
of schizophrenia far away from the environmental
factors, but still the environment has its effect in
completing the picture.
Conclusion: genetics has its role in etiology of the
disorder but its not transmitted from parents to children
in mandelian way but its multifactorial
o Influenza infection: second-trimester exposure may increase the risk
of the fetus subsequently developing schizophrenia
Maternal measles and rubella infections: associations also found
o Premature rupture of membranes, preterm labour, low birth weight
and foetal hypoxia during delivery
o Stressful life events: common precipitant of first episode psychosis
o High expressed emotion (EE): over-involvement, critical comments
and hostility from family
members > 35 hours/week increase the risk of relapse of schizophrenia
o Age and gender: male schizophrenia patients tend to have more
severe disease, early onset, more structural brain diseases, worse
premorbid adjustment compared to female patients
o Advanced paternal age at time of birth: risk factor for offspring to
o Social class: controversial whether low social class is caused by
schizophrenia or is an effect of the course and nature of the disease
o Urban habitation: higher prevalence of schizophrenia in urban
areas compared to rural areas due to interaction of genetic factors,
migration, higher rates of social deprivation, more social problems;
favourable outcome in non-industrialised countries vs industrialised
o Ethnicity: Afro-Caribbean immigrants to the UK have higher risk of
schizophrenia even in the second generation
Symptoms of schizophrenia
We can divide the symptoms of schizophrenia into three groups:
positive, negative, and cognitive.
1. Positive Symptoms Are Abnormal Behaviors. Positive symptoms are
symptoms that are present and usually observable. These are the
symptoms associated with an acute psychotic episode and are
primarily disorders of thought and presentation. They include
hallucinations, delusions, and other bizarre behaviors
Commanding , commenting and 3rd person hallucinations ) )Auditory
Somatic or tactile hallucinations
(Paranoid delusion (Persecutory delusions , Delusions of reference , Grandiose delusion
Delusions of jealousy
Delusions of guilt or sin
Delusions of being controlled
Clothing and behavior
Social and sexual behavior
Repetitive or stereotyped behavior
Positive formal thought disorder
Loss of association
Pressure of speech
2.Negative Symptoms Are the Absence of Normal Behaviors. Negative symptoms are defined by their
absence and sometimes also called deficit symptoms. They are commonly associated with the progression of
the illness. These
• 1. Absence of affect
Unchanging facial expressions
Decreased spontaneous movement
Poor eye contact
Lack of vocal inflections
Poverty of speech
Poverty of content of speech
Grooming and hygiene
Impersistence at work or school
Recreational interests and activities
Sexual interest and activities
Intimacy and closeness
Relationships with friends
Inattentiveness during testing
3.Cognitive Symptoms Are Impairments in Normal
Cognitive Functions. The cognitive symptoms of
schizophrenia may be subtle, particularly early in the
disease process, but are very impairing and account
for much of the disability associated with this disorder.
impairments of attention, working memory, and
Common Psychopathology in Speech
Neologism Invention of own words which hold special
meaning for the speaker and cannot be found in
the English language; condensations of several other
words e.g. a patient refers to clouds as ‘lambrain’ because
they look like lambs and produce rainfall
Echolalia: Psychopathological repeating of words or
phrases of one person
by another; tends to be repetitive and persistent. Seen in
certain kinds of
schizophrenia, particularly the catatonic types
Psychopathology in Thought
Circumstantiality : Speech takes a long time to reach the point because it
includes a great deal of unnecessary details
Occurs in schizophrenia, dementia, temporal lobe epilepsy and normal people
Tangentiality Stream of thought diverges from the topic and speech appears to
be unrelated and irrelevant at the end
oOccurs in schizophrenia and mania
Flight of ideas Continuous speech where topics jump rapidly from one to
another and there is a logical link between topic
oOccurs in mania; accompanied by pressure of speech
Loosening of associationsDiffuse and unfocused speech where topics seem
disconnected; difficult for the listener to establish a logical link between topics
Thought insertion Patient feels that external thoughts which do not belong to them
are being inserted into their mind
Thought withdrawal Patient feels that their own thoughts are being taken away
Thought broadcasting Patient feels that their own thoughts are being made
known to others through broadcasting much like a radio or television station
delusion is a flase belief of morbid origin and is not consistent with his culture or
society. There are types of delusions (primary, secondary, …etc) but we want to
demonstrate only the following ones:
The following types are the predominate ones of delusional disorders:
1) Persecutory type:
The patient thinks that people want to hurt him and the supposed persecutors of
the deluded patient may be definite people in the environment like members of
family, neighbours, or friends or ….etc …. Others
2) Grandiose type
Here, the patient has delusions of inflated worth, power, knowledge, identity or
special relationship to a diety or famous person. In addition, he feels that he is
important, intelligent or a prophet.
3) Erotomatic type (delusions of love)
Erotomatic comes from erotic (sexual desire) and mania. Here , the patient thinks
that some person is in love with him. He may pester the victim with letters and
other behavior . if there is no response to the letters, then he thinks that are
people (enemies) who have wicked intention.
4) Somatic type
Here, the patient feels that he has some physical defect or general medical
condition . he may think that he has a tumor, tuberculosis, syphilis and other diseases .
Example / the following type, here the patient feels the presence of a bad smell coming
from his body (mouth, rectum, vagina …), so he tries to avoid other people so that they
cannot detect this disorder.
Example/ The dysmorphie type here, the patient feels that his nose is deviated, his mouth
is wide , his ears outwards (bat ears) , …. Etc his body is not well organized,… he tries to
correct these abnormalities by consulting doctors an asking them to do a plastic surgery
on his body, but the doctors tell him that he does not suffer from and abnormality and
that his body is normal. After that , the patient continues to consult doctors seeking for
help and intervention with his problem.
Example / Infestation type , here, the patient feels that he is infested by parasites, worms,
insects, …..etc. either in the skin (external) or in the GIT and other internal organs
5) Nihilistic type
Here, the patient feels that or denies the existence of body, his mind, his loved
ones, and the world around him. he thinks that his body is dead, the world has
He may think that the day is coming or that he is, so there is so need to drink and
eat because he will never die.
This type of delusions may be seen in severe agitated degree of depression or
schizophrenia or in delusional disorder
6) Jealous type
Here , the patient that his/her sexual partner is unfaithful …. But is most common
in males. This type of delusional disorder is more common in eastern countries
due to cultural factors that makes the husband think that his wife is a part of him,
his wife is not equal to him or that his wife is his own and he can do whatever he
wants with her. In addition, the husband thinks that and thing related to his wife
is related to him.
However, the patient with this type delusion thinks that his wife has a sexual
relationship with another person. So the patient to observe her behavior and may
follow her in the streets to detect her partner. He may interrogate his wife by
asking questions and may even search his wife's underclothes for stain of
seminal fluid. Sometimes , the wife is beaten to make her confession and not
uncommonly murder is attempted or committed. It's better to the wife not to
confess because the patient may kill her after wards . It has been found that
faithful loyal with no any sexual relationship.
7) Mixed type
Here , the patient has delusion of more than one of the previously mentioned
types, but no one theme predominates.
In addition to the specific types of delusional disorders, we have the following
Couvades syndrome delusion type
Here, the patient feels the same symptoms of his wife who is pregnant in the first
three months like nausea , anorexia, vomiting, fatiquability, ..etc
It's said to be a neurotic disorder
Paraphrenic delusional type:
Here, the patient has paranoid delusions and auditory hallucinations but the
social and occupational function is not deteriorated
Capgras delusion type
Here, the patient feels that the person in front is not the same person but
similar to him. It occurs usually abruptly and can be considered as hysterical
delusion in which the patient gains attention as hysterical delusion in which the
patient gains attention
Diagnostic Criteria for
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
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.
Brief psychotic disorder
The picture of the positive schizophrenic symptoms
lasting for one day to one month with no occupation
and social dysfunction or deterioration with exclusion
of other condition. The patient returns usually to
normal state with very good prognosis.
Note: other psychotic and medical disorders must be
excluded and also drugs (hallucinogens) must also
The picture is similar to that of schizophrenia for
first four symptom (characteristic symptoms) without
the fifth one to be involved (negative symptoms). The
duration is usually 1-6 month.
The patient with positive symptoms for 1-6 month has
a good prognosis because remission is usually
expected before 6 months.
The social and occupational deterioration is not
observed and medical conditions which may cause
schizophrenic like symptoms for a limited period of
time must be excluded.
DSM-5 Diagnostic Criteria: Schizophrenia
I. Presence of ≥ 2 of the following symptoms over a 1 month period (at least one of which
must be a, b or c), such that an individual’s premorbid level of functioning is affected in
several major domains of life
c. Incoherent and disorganised speech
d. Disorganised or catatonic behaviour
e. Negative symptoms/diminished emotional expression
II- social and occupational deterioration (dysfunction)
ﻋﻠﻰ ﻗﺎدر ﻏﻴﺮ ﻳﺼﺒﺢ اﻟﻤﺮﻳﺾ ﻓﺎن وﻛﺬﻟﻚ واﻻﺻﺪﻗﺎء واﻻﻗﺎرب اﻻﺳﺮة ﻣﻊ اﻻﺟﺘﻤﺎﻋﻴﺔ ﻋﻼﻗﺎﺗﻪ ﺗﻀﻄﺮب اﻟﻤﺮﻳﺾ
دراﺳﺘﻪ او ﻋﻤﻠﻪ او وﻇﻴﻔﺘﻪ ﻓﻲ اﻻﺳﺘﻤﺮار
III- The symptoms of the patient must continue for six months or more
Note : If the symptoms last less than 6 months then the disorder may be either brief
psychotic disorder (1 day- 1 month) or schizophreniform disorder (1-6 months)
IV- the disturbance is not due to effects of a substance (e.g. drug abuse, medication ) or a
general medical condition.
V- relationships to pervasive developmental disorders like autistic disorders . In which
addition diagnosis of schizophrenia is made on if prominent hallucination and delusion are
Diagnostic Criteria for
A. An uninterrupted period of illness during which there is a major
mood episode (major depressive or manic) concurrent with
Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1:
B. Delusions or hallucinations for 2 or more weeks in the absence of
a major mood episode (depressive or manic) during the lifetime
duration of the illness.
C. Symptoms that meet criteria for a major mood episode are
present for the majority of the total duration of the active and
residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition.
Drug induce psychosis
The symptoms of psychotic disorder may appear
due to either misuse (abuse) of drug or withdrawal of
drug. The symptoms that are induced are not related
to the drug directly, but occur due to changes in the
neurotransmitter at the synapses.
Note: certain drugs (with no misuse, abuse or
withdrawal) may cause psychotic symptoms (ex:
bromocriptine dopamine agonist)
Diagnostic Process for
-Physical and lab exams rule out psychotic disorder
due to a medical condition and substance-induced
-Imaging (CT, MRI, PET) are seldom helpful in
-The diagnosis is commonly made from history and
the mental status exam
-There are currently no reliable biomarkers for
diagnosis or severity
Schizophrenia requires lifelong treatment, even when
symptoms have subsided. Treatment with medications
and psychosocial therapy can help manage the
condition. In some cases, hospitalization may be
A psychiatrist experienced in treating schizophrenia
usually guides treatment. The treatment team also may
include a psychologist, social worker, psychiatric nurse
and possibly a case manager to coordinate care. The
full-team approach may be available in clinics with
expertise in schizophrenia treatment.
Medications are the cornerstone of schizophrenia treatment,
and antipsychotic medications are the most commonly
prescribed drugs. They're thought to control symptoms by
affecting the brain neurotransmitter dopamine.
The goal of treatment with antipsychotic medications is to
effectively manage signs and symptoms at the lowest possible
dose. The psychiatrist may try different drugs, different doses
or combinations over time to achieve the desired result. Other
medications also may help, such as antidepressants or anti-
anxiety drugs. It can take several weeks to notice an
improvement in symptoms.
Because medications for schizophrenia can cause serious
side effects, people with schizophrenia may be reluctant to
take them. Willingness to cooperate with treatment may affect
drug choice. For example, someone who is resistant to taking
medication consistently may need to be given injections
instead of taking a pill.
These first-generation antipsychotics have frequent and
potentially significant neurological side effects, including
the possibility of developing a movement disorder
(tardive dyskinesia) that may or may not be reversible.
First-generation antipsychotics include:
These antipsychotics are often cheaper than second-
generation antipsychotics, especially the generic
versions, which can be an important consideration when
long-term treatment is necessary.
These newer, second-generation medications are generally
preferred because they pose a lower risk of serious side effects
than do first-generation antipsychotics. Second-generation
Clozapine (Clozaril, Versacloz)
Long-acting injectable antipsychotics
Some antipsychotics may be given as an intramuscular or
subcutaneous injection. They are usually given every two to
four weeks, depending on the medicationThis may be an
option if someone has a preference for fewer pills and may
help with adherence.
Common medications that are available as an injection
Aripiprazole (Abilify Maintena, Aristada)
Paliperidone (Invega Sustenna, Invega Trinza)
Risperidone (Risperdal Consta, Perseris)
Once psychosis recedes, in addition to continuing on medication,
psychological and social (psychosocial) interventions are important.
These may include:
Individual therapy. Psychotherapy may help to normalize thought
patterns. Also, learning to cope with stress and identify early warning
signs of relapse can help people with schizophrenia manage their
Social skills training. This focuses on improving communication and
social interactions and improving the ability to participate in daily
Family therapy. This provides support and education to families dealing
Vocational rehabilitation and supported employment. This focuses on
helping people with schizophrenia prepare for, find and keep jobs.
Most individuals with schizophrenia require some form of daily living
support. Many communities have programs to help people with
schizophrenia with jobs, housing, self-help groups and crisis situations.
A case manager or someone on the treatment team can help find
resources. With appropriate treatment, most people with schizophrenia
can manage their illness.
During crisis periods or times of severe symptoms,
hospitalization may be necessary to ensure safety,
proper nutrition, adequate sleep and basic hygiene.
For adults with schizophrenia who do not respond to
drug therapy, electroconvulsive therapy (ECT) may be
considered. ECT may be helpful for someone who also