Pathophysiology of psychosis pdf

Delusions are contrasted with overvalued ideas, which are unreasonable beliefs or ideas that are held with strong, but not delusional, conviction. When a false belief involves a value judgment, it may be regarded as delusional only when the judgment made is so extreme that it is not credible. Delusions are distinct from confabulation, which refers to the automatic and nondeceitful fabrication of information, usually of an autobiographical or episodic nature, by a patient with concurrent declarative memory impairments and executive dysfunction.

Delusional misidentification syndromes. Delusional misidentification syndromes Table 10 share the theme of doubles ie, duplication of self, others, or the environment.

They are associated with impairments in facial processing and are closely related to and sometimes co-occur with reduplicative paramnesia. A subset of the population with genetic, epigenetic, and developmental risk factors may, with sufficient exposure to risk-modifying social and environmental factors, be prone to developing persistent psychotic symptoms.

It also may yield insights into the risk factors for and mechanisms of psychosis associated with neurologic conditions. This model aligns well with the National Institute of Mental Health NIMH Research Domain Criteria RDoC framework, within which phenomena such as delusions and hallucinations are studied in relation to the operations of underlying neural systems across the conditions in which they occur, rather than in relation to the categorical psychiatric disorders with which they may be associated.

In this light, it is not surprising that psychosis is listed as a feature of multiple psychiatric disorders presented in the DSM Although psychosis is the defining feature of the schizophrenia spectrum disorders ie, schizophrenia, schizoaffective disorder, delusional disorder, schizophreniform disorder, and brief psychotic disorder , it also occurs in some people with bipolar disorder during either a manic or depressive episode as well as in some individuals during a major depressive episode associated with major depressive disorder.

In those conditions, the psychotic symptoms usually delusions may be thematically either congruent or incongruent with the prevailing mood. Psychotic symptoms ie, hallucinations without insight, delusions may develop during either intoxication or withdrawal from substances and, in some cases, may become chronic sequelae of prior substance use substance-induced psychotic disorder.

When individuals with obsessive-compulsive disorder lack insight into the pathologic nature of their obsessions, their obsessions are described as delusions. The psychosis proneness-persistence model and RDoC approach suggests that the presence of hallucinations or delusions reflects disturbances in the neural systems underlying these symptoms regardless of the categorical psychiatric or neurologic disorder with which they are associated. A complete review of psychosis as it occurs in each of these conditions is beyond the scope of the present article.

Readers are encouraged to review the relevant sections of the DSM-5 and to familiarize themselves with the current criteria for these conditions. The DSM-5 marks a shift from the presentation of schizophrenia as the archetypal psychotic disorder to its consideration as one of several psychotic disorders existing on a spectrum of psychopathology.

Disorders along the schizophrenia spectrum differ from one another by the type, number, complexity, severity, and duration of the psychotic symptoms and associated features that define them. The number, complexity, and duration of symptoms required for a given diagnosis increase with movement from the mild to the severe ends of the schizophrenia spectrum. Assessment of this constellation of symptoms with these measures is described in the DSM-5 as useful for characterizing these conditions, predicting important aspects of the illness eg, cognitive and neurobiological deficits , informing treatment planning and prognosis, and monitoring symptom severity over time.

The severity of the disorders in this section of the DSM-5 may be assessed with this scale, which the APA has made freely available for clinical use www.

Given the emerging nature of this measure, the DSM-5 encourages, but does not require, using the Clinician-Rated Dimensions of Psychosis Symptom Severity scale to specify severity of illness in the schizophrenia spectrum disorders. Schizotypal personality disorder. At the mild end of the schizophrenia spectrum disorders is schizotypal disorder also known as schizotypal personality disorder. Schizotypal disorder is characterized by social and interpersonal deficits that reduce the capacity for, and produce marked discomfort with, close relationships.

These deficits are often accompanied by unusual perceptual experiences illusions and cognitive distortions ideas of reference, suspiciousness or paranoia, odd beliefs, or magical thinking that are held without delusional conviction similar to, but less severe than, those experienced by people with schizophrenia.

As noted by Chemerinski and colleagues, 20 schizotypal disorder and schizophrenia feature cognitive, social, and attentional deficits based in neurodevelopmentally mediated temporal and prefrontal cortical pathology. These deficits are milder in people with schizotypal disorder than in those with schizophrenia, possibly as a result of preserved capacity in the schizotypal brain to recruit related brain regions and thereby compensate for dysfunctional areas.

Additionally, people with schizotypal disorder appear to be less vulnerable to psychosis as a result of the preservation of protective factors against the psychotogenic effects of subcortical dopaminergic hyperactivity. Although the criteria for schizotypal disorder have not changed substantively between the DSM-IV-TR and DSM-5 , the presentation of this condition as both a schizophrenia spectrum disorder and a personality disorder is a noteworthy change in its classification.

Delusional disorder. Delusional disorder encompasses a broader range of the spectrum of psychosis severity in the DSM-5 than in the prior edition of this manual. If present, hallucinations must be related to the delusional theme eg, tactile hallucinations of bugs on the skin in a patient with delusions of parasitosis.

In the DSM-IV-TR , bizarre delusions exceeded the criteria for delusional disorder and were sufficient grounds for a diagnosis of schizophrenia even in the absence of hallucinations, disorganized thought or behavior, catatonia, or negative symptoms.

As a result, the presence of either ordinary or bizarre delusions or both is now consistent with a diagnosis of delusional disorder, although the presence of bizarre content is used as a specifier in this diagnosis. Brief psychotic disorder. This diagnosis is defined by the presence of delusions, hallucinations, formal thought disorder ie, disorganized speech , or abnormal psychomotor behavior grossly disorganized or catatonic behavior , not better explained by another mental disorder, substance use disorder, or medical condition, lasting at least 1 day but less than 1 month, with eventual full return to premorbid function.

Negative symptoms are not among the diagnostic criteria for this condition. The DSM-5 adds a specifier for the presence of catatonia, as well as a coding note directing the use of the additional Schizophreniform disorder. Schizophreniform disorder represents a point on the spectrum between brief psychotic disorder and schizophrenia.

Analogous to changes made to the criteria for schizophrenia, this condition is defined by the presence of two or more psychotic and related symptoms delusions, hallucinations, disorganized speech reflecting formal thought disorder, abnormal psychomotor behavior such as grossly disorganized or catatonic behavior, negative symptoms —at least one of which must be delusions, hallucinations, or disorganized speech—lasting at least 1 month but less than 6 months.

The DSM-5 , in contrast to the DSM-IV-TR , permits making a provisional diagnosis of schizophreniform disorder when a diagnosis must be made before the end of this time period without waiting for possible recovery. It also clarifies the exclusion of schizoaffective disorder, major depressive disorder, and bipolar disorder by specifying that no major depressive or manic symptoms may occur with active-phase psychotic symptoms or, if such symptoms have been present, that they have been present for a minority of the total active and residual phases of the illness.

As with brief psychotic disorder, an additional specifier and related coding note have been added to indicate the presence of comorbid catatonia. The DSM-5 includes substantive changes to the diagnostic criteria for schizophrenia.

The core criteria continue to require the presence of two or more psychotic and related symptoms delusions, hallucinations, disorganized speech reflecting formal thought disorder, abnormal psychomotor behavior such as grossly disorganized or catatonic behavior, negative symptoms —at least one of which must be delusions, hallucinations, or disorganized speech—that have been present for at least 6 months including 1 month, or less if treated successfully, of active psychotic and related symptoms.

These symptoms also must be associated with impaired functioning in one or more major life areas such as self-care, work, interpersonal relations, or academics. The DSM-IV-TR permitted diagnosing schizophrenia when first-rank delusions or auditory hallucinations occurred in the absence of other symptoms.

However, first-rank symptoms are not specific to schizophrenia and may occur in manic and depressive episodes with psychotic features, temporal lobe epilepsy, dissociative identity disorder, and other psychiatric conditions. This change is coordinated with the DSM-5 revised criteria for delusional disorder such that patients presenting only with bizarre delusions, and thereby failing to meet criteria for schizophrenia, can now be diagnosed with delusional disorder.

As with schizophreniform disorder, clarification of the exclusion of schizoaffective disorder, major depressive disorder, and bipolar disorder is offered, and an additional specifier and related coding note have been added to indicate the presence of comorbid catatonia. These subtypes paranoid, disorganized, catatonic, undifferentiated, residual were defined previously by the predominant symptom at the time of a given evaluation.

However, the validity of these subtypes was controversial given their longitudinal instability, overlapping features, and failure to consistently predict outcomes. Schizoaffective disorder.

Defining schizoaffective disorder has presented challenges to the psychiatric research community. Others describe it as a mood disorder in which mood episode—related psychotic symptoms do not fully remit. Still others view it as the simple co-occurrence of two relatively common but etiologically distinct psychiatric illness types, schizophrenia and a mood disorder.

The problem of schizoaffective disorder remains unresolved in the DSM-5 , although criteria are revised in a manner that is likely to reduce the frequency with which it is diagnosed. As in the DSM-IV-TR , the current diagnostic criteria for schizoaffective disorder require an uninterrupted period of illness during which a major mood episode occurs concurrently with a disturbance meeting Criterion A for schizophrenia two or more of the following: delusions, hallucinations, disorganized speech reflecting formal thought disorder, abnormal psychomotor behavior, negative symptoms, at least one of which is delusions, hallucinations, or disorganized speech.

Over the lifetime of the illness, delusions or hallucinations also must occur for at least 2 weeks in the absence of either a manic or depressive episode. This requirement of a 2-week or longer episode of psychosis in the absence of mood symptoms distinguishes schizoaffective disorder from either bipolar or depressive disorders with psychotic features, in which psychotic symptoms occur only during mood episodes.

Course specifiers for bipolar or depressive subtypes of schizoaffective disorder and a new specifier for catatonic features are presented in the current criteria. This criterion requires assessment of mood symptoms over the entire course of a psychotic illness rather than merely the current period of illness; if mood symptoms are present only for a relatively brief period eg, during only 1 year of a 4-year psychotic illness , then a diagnosis of schizophrenia is made instead of a diagnosis of schizoaffective disorder.

Other specified schizophrenia and other psychotic disorders. The DSM-5 introduces this subcategory to provide for the diagnosis of four conditions involving psychotic symptoms that do not meet full criteria for any of the schizophrenia spectrum disorders but nonetheless are issues of clinical concern.

Persistent auditory hallucinations , denoting the persistent presence of auditory hallucinations occurring in the absence of other psychotic features. Delusions with significant overlapping mood episodes , which is most appropriately used when a patient otherwise meeting criteria for delusional disorder also experiences overlapping mood episodes for a substantial portion of the delusional disturbance.

Attenuated psychosis syndrome , which describes a condition in which psychotic-like symptoms are present but are less severe and more transient than in schizophrenia, and for which insight is relatively maintained.

Unspecified schizophrenia spectrum and other psychotic disorder. It also applies to presentations about which insufficient information exists to make a more specific diagnosis. The practical usefulness of this diagnosis is not established. A year-old previously healthy man was brought in by his parents for evaluation of paranoid ideation. The parents reported that the patient had always been a loner, worked from home as a computer programmer, and spent most of his leisure time in his room browsing the Internet, watching detective shows on television, and listening to a police scanner.

A little over 1 month prior to presentation, he began refusing to leave his room, keeping the curtains drawn constantly, and taking copious notes about the comings and goings of his neighbors. After a week of these new behaviors, his parents asked him to explain the changes to his routine. He told them that a black sedan had begun parking across the street from their home each evening and departing early each morning, leading him to conclude that he was the subject of surveillance by the Federal Bureau of Investigation.

When his parents informed him that the car was recently purchased by their longtime next-door neighbor and family acquaintance, he then concluded that the neighbor was the federal agent surveilling him. Serum laboratory studies, urine toxicology, and MRI of the brain were normal. The patient presented with a nonbizarre delusion as his sole symptom. The presence of this type of delusion for more than 1 month in the absence of prominent hallucinations, when not better explained by a known psychotic disorder or mood disorder with psychotic features and not attributable to the physiologic effects of a substance or another medical condition, is consistent with a provisional diagnosis of delusional disorder A detailed review of the clinical features of psychosis associated with neurologic conditions is beyond the scope of this review, as the literature describing the phenomenology, epidemiology, and putative neurobiology of hallucinations and delusions associated with neurologic disorders has expanded rapidly over the last 2 decades.

As a brief review, Table 25,26 summarizes and comments on the psychotic symptoms associated with more than a dozen neurologic conditions and their possible anatomic correlates. Useful direction for the evaluation and management of patients with schizophrenia spectrum and related disorders, 27 as well as other psychiatric and neurologic conditions in which psychotic symptoms developed, is found in the APA Clinical Practice Guidelines psychiatryonline.

Thus, clinicians evaluating and developing treatment plans for patients with primary or secondary psychoses are encouraged to access guidelines in the National Guideline Clearinghouse repository and similar resources, 32—34 to integrate the guidance they offer with that presented in relevant professional society guidelines especially when those guidelines are more than 5 years old , and to supplement all guidelines with findings presented in subsequently published meta-analyses and systematic reviews.

Patients should be involved in psychiatric, neurologic, and general medical history taking to the extent that their clinical status allows, and, whenever possible, collateral and corroborative history should be obtained from family members or others knowledgeable about the patient and from medical records. Evaluation for potentially causative or contributory medications eg, prodopaminergic or anticholinergic agents and substance use disorders is essential.

Evaluation for manic and depressive episodes current and lifetime anchored to DSM-5 criteria should be performed, as strict adherence to these criteria is required to distinguish between schizophrenia mood disorders with psychotic features and schizoaffective disorder.

The DMS-5 encourages use of the Clinician-Rated Dimensions of Psychosis Symptom Severity scale to rate the severity of both manic and depressive symptoms associated with schizophrenia spectrum and other psychotic disorders. The DSM-5 directs clinicians to interpret measures using normative data for age and for socioeconomic status; as few measures provide socioeconomic status—adjusted norms, normative data for education may serve as the closest proxy for this adjustment.

The Clinician-Rated Dimensions of Psychosis Symptom Severity scale rates the severity of cognitive impairment in increments of standard deviations SD below the mean for age and socioeconomic status 0: no impairment; 1: equivocal, between 0 and 0.

Systematic reviews and meta-analyses demonstrate that typical first-generation and atypical second-generation antipsychotics are similar with respect to their beneficial effects on the frequency and severity of hallucinations and delusions. Acetylcholinesterase inhibitors, adjunctively or alternatively, may reduce psychosis in patients with Alzheimer disease, 46 Parkinson disease dementia, 47 diffuse Lewy body disease, 48 and, to a lesser extent, schizophrenia and related conditions.

Evidence of benefit from antipsychotic treatment of psychotic symptoms is mixed in patients with psychosis associated with Alzheimer disease, 50,51 modest in Parkinson disease for which clozapine and quetiapine are the preferred agents for psychosis that persists despite stepwise reductions in prodopaminergic medications , 52 and limited for most other neurologic conditions.

While acknowledging the limits of the evidence base for the treatment of psychosis associated with neurologic conditions, individual patients experiencing secondary psychosis may benefit, nonetheless, from judicious administration of antipsychotic medications, especially when other medications and nonpharmacologic interventions do not provide adequate relief from psychotic symptoms.

Whether used to treat primary or secondary psychoses, antipsychotic treatment—related pretreatment evaluation of weight; metabolic status; cardiac, sexual, and neurologic especially motor function; and hematologic health as well as periodic monitoring for changes in these areas during treatment is recommended.

There are other causes, such as sleep deprivation, general medical conditions, certain prescription medications, and the misuse of alcohol or other drugs, such as marijuana. A mental illness, such as schizophrenia, is typically diagnosed by excluding all of these other causes of psychosis.

To receive a thorough assessment and accurate diagnosis, visit a qualified health care professional such as a psychologist, psychiatrist, or social worker.

Studies have shown that it is common for a person to have psychotic symptoms for more than a year before receiving treatment. Reducing this duration of untreated psychosis is critical because early treatment often means a better recovery. A qualified psychologist, psychiatrist, or social worker will be able to make a diagnosis and help develop a treatment plan. People with psychosis may behave in confusing and unpredictable ways and may become threatening or violent.

However, people with psychotic symptoms are more likely to harm themselves than someone else. If you notice these changes in behavior, and they begin to intensify or do not go away, it is important to seek help. Research supports a variety of treatments for early psychosis, especially coordinated specialty care. RAISE studied coordinated specialty care treatments and the best ways to intervene after people begin to experience psychotic symptoms and to help them return to a path toward productive, independent lives.

Coordinated specialty care involves the following components:. Individuals with psychosis should be involved in their treatment planning.

Their needs and goals should drive their treatment programs, which will help them stay engaged throughout the recovery process. It is important to find a mental health professional who is trained in psychosis treatment and who makes the patient feel comfortable.

NIMH does not endorse specific early psychosis clinics or evaluate professional qualifications or competence of individual practitioners. However, there are several organizations that may be able to assist you in finding a treatment program in your area.

This list may not be comprehensive and does not constitute an endorsement by NIMH. For additional resources, visit our Help for Mental Illnesses webpage.

Communicating well with your doctor or health care provider can improve your care and help you both make good choices about your health. For additional resources, including questions to ask your doctor, visit the Agency for Healthcare Research and Quality. Statistics NIMH statistics pages include statistics on the prevalence, treatment, and costs of mental illness for the population of the United States.

Catatonic behavior appears as a notable decrease in reactivity to the external environment, which can consist of psychomotor retardation, immobility, and severe rigidity with a lack of verbal response, to an excitatory state of aimless and unrestricted motor activity. Negative symptoms are a decrease or loss in normal functioning, and their components can commonly be confused with those of depressive disorders. The prodrome phase of schizophrenia commonly presents with negative symptoms.

Psychomotor retardation, lack of energy, interest, concentration, and pleasure in activities once found pleasurable anhedonia are all potential features as well. Catatonia is another potential manifestation of psychosis that can present with either extreme negativism or catatonic excitement. As with any other medical or psychiatric condition, the interview is of the utmost importance for guiding the treatment plan. As usual, one starts by obtaining a thorough history.

The clinician should also be able to recognize the psychiatric patient may not always be able to give the most concise history due to their underlying condition. Of equal importance to the history, and an indispensable component of the psychiatric interview is the mental status exam MSE. Aside from a urinary toxicology screen, a standard medical workup can help to rule out non-psychiatric causes of psychosis, as well as some additional tests if clinical suspicion permits.

These may include:. It is important to note that some substances which correlate to psychotic episodes bath salts, certain synthetic strains of cannabis, psychedelics may not show up on basic drug screen panels. It is only when clinicians have officially ruled out a substance, medication-induced, or other underlying medical causes that one can consider a primary psychotic disorder.

The management of a psychotic patient varies greatly depending on the origins of the psychosis. A psychiatrist should evaluate any patient experiencing an episode of psychosis. Antipsychotic medications are the gold-standard treatment for psychotic episodes and disorders, and the choice, dosing, and administration of the medication will largely depend on the scenario. Antipsychotics are generally the treatment for schizophrenia spectrum disorders.

Initial dosing should be at a low dose and titrated up as needed. Of note, there has been a long-standing debate as to whether second-generation antipsychotics are more efficacious than the first generation. Antipsychotics have also been shown to be most effective in treating the psychotic symptoms of drug-induced psychosis, mania, delirium, [19] the psychotic features of depression, as well as the psychotic features of dementia and other neurologic conditions.

Of course, beyond acute psychosis, treating the underlying cause is always an appropriate course of action. Antipsychotic medications have demonstrated to be most effective in positive symptoms of psychosis discussed earlier hallucinations, delusions, disorganized thoughts, and behavior and less useful for negative symptoms. Of note, clozapine and olanzapine specifically have been shown to reduce the risk of suicide in psychotic patients.

Benzodiazepines have evidence as an effective treatment for catatonic symptoms of psychosis. Along with medications, family and caregivers also play an important role in the management of a psychotic patient, including providing a safe and therapeutic environment for the patient, as well as interacting with them in and calm, empathetic manner. In the scenario of an agitated, potentially aggressive, acutely psychotic patient at risk of harming themselves or someone else, they should be hospitalized and placed in the care of health care professionals.

An injectable form of a typical antipsychotic with a benzodiazepine is most effective in this case. Along with medications, cognitive behavioral therapy can play an integral role in the treatment of patients with psychotic symptoms.

Lastly, it is critical to note that for acute onset psychosis in patients, ultimately developing a schizophrenia-spectrum psychotic disorder, early intervention may improve clinical outcomes. Delays in treatment have statistical links with poorer treatment outcomes. To differentiate between psychoses associated with a primary psychotic disorder and psychotic disorders associated with other medical or neurologic conditions, one can examine the following factors:.

Age of onset: This is one of the most important factors when determining the etiology of a psychotic episode. The primary psychotic disorder will usually present in the late teens to the early thirties. Men typically present with the condition earlier than women.

The older the patient, the higher the risk for medical or neurological psychosis, especially in the hospital setting. The pattern of onset: Primary psychotic disorder may present subtly, often with a prodromal phase that may be confused with another psychiatric disorder e. Medical or neurological psychosis will usually present acutely. Specific primary psychotic disorders, with their subtypes, along with all other psychotic disorders, will be discussed in detail in other activities.

The course for schizophrenia was once believed to be unvaryingly poor, although now studies have shown there is potential for good outcomes. The multitude of newer medications, along with an option for long-acting injectable antipsychotics, has given patients a variety of treatment options along with addressing compliance issues. As stated earlier, early intervention, along with intensive treatment, seems to be of utmost importance in long-term outcomes.

There is little data supporting evidence either way for a single psychotic episode related to a medical or neurologic condition, and prognosis would be condition-dependent. Treating the current episode, along with the underlying illness, would be considered the best course of action.

In any psychotic episode, regardless of etiology, there is always a risk of danger to self or others. These patients require admission to a safe and therapeutic medical setting. Paranoia, fear, suspicion, or other symptoms of psychosis may prevent a patient from getting the help they need initially, as well as hinder their capability for medication and treatment compliance.

There are significant side effects with antipsychotic medications, which may include extrapyramidal symptoms EPS , metabolic syndrome, cardiac abnormalities, anticholinergic effects, sexual side effects, tardive dyskinesia, and many more. Psychotic disorders can lead to significantly decreased daily functioning, along with an increased risk of suicide compared to the general population.

Psychosis is a common, yet extremely, distressing set of symptoms that healthcare providers will undoubtedly face at some point in their training or practice. As discussed, there is a myriad of underlying causes for a patient presenting with a psychotic episode, including a primary psychiatric disorder, substance-induced, neurologic, or medical induced.

A proper medical workup, along with a psychiatric evaluation, is always warranted. While it is possible to treat the initial symptoms of a patient experiencing an episode of psychosis, individual patients, especially those with primary psychotic disorders, will generally require ongoing care for the remainder of their lifetime. Many times, the standard treatment is not enough and does not address the subjective psychosocial stressors a patient may be experiencing.

Patients with severe mental illness experience high treatment dropout rates. New, emerging studies focus on how healthcare providers can enhance healthcare team outcomes through community engagement. Specific subgroups of patients experiencing mental illness have been historically difficult to engage: those with first-episode psychosis, homeless populations, and those with comorbid substance use.

Poor treatment engagement correlates with poor clinical outcomes, relapse, and re-hospitalization. This activity will focus below on three emerging, innovative, recovery-oriented techniques for engagement. Technology can serve as a medium for more significant lines of communication among people. It may assist in helping to connect with others experiencing a similar illness or hardship without facing the potential shame or guilt of seeking help in person.

Some people would like to seek assistance in person, but due to limited access due to geographical location, may be unable to. Communication through technology may also be more feasible economically, particularly in the uninsured population, or those lacking funds for transportation. The majority of young adults use social media and may be more amenable to seeking help in this fashion. Being able to touch base with a healthcare professional may decrease unnecessary hospitalizations.

Some studies report some patients who have difficulty complying with treatment and may be untrustworthy of authority figures. Other patients may feel judged, marginalized, or stigmatized when engaging in traditional healthcare settings. Peer provider networks have emerged as a way to engage with patients and address their particular needs as well provide them with a relatable social network.

Patients have noted to experience an increased sense of self-determination, self-awareness, and positive effects on engagement. Patients also feel like they finally have someone advocating for them. Studies have shown that patients receiving peer support, in the beginning, had been more engaged and motivated with treatment six months from the start.

Peer support groups were shown to be particularly crucial for Army and combat veterans, specifically decreasing internal and external stigma.

Mentally ill from ethnic minority groups are less likely to engage in mental health treatment than non-Hispanic whites. Thus, providing culturally sensitive care is of utmost importance. The cultural formulation interview CFI is a 16 item questionnaire new to the DSM-V that not only seeks to understand cultural and social structures but individual circumstances as well.