General Considerations and Diﬀerential Diagnosis:
Schizophreniform Disorder Clinical Manifestations and Diagnosic Considerations The clinical presentation is identical to schizophrenia, however impairment in function is not a requirement. The required duration of symptoms is of at least a month but less than 6 months. If symptoms persist for longer than 6 months it is appropriate to change the diagnosis to schizophrenia.20 The diagnosis requires for other pathologies that may be responsible for the clinical manifestations (e.g., medical and drug use) to be ruled out before a diagnosis of schizophreniform disorder is made. It is not clear if schizophreniform disorder is a diﬀerent disorder or just a more acute, better prognosis type of schizophrenia. Subtypes/Specifiers With good prognostic features: • Good premorbid level of function • Abrupt onset • Confusion • Absence of flat aﬀect Without good prognostic features: when less than 2 of the above features are present21 Epidemiology The prevalence is low overall. There may be diﬀerences between developed countries (estimated around 0.2%) and developing countries (estimated around 1%).22 Treatment Considerations • Hospitalization is recommended if the acute psychotic symptoms result in danger to self or others or significant impairment. • Acute psychosis should be treated with antipsychotics. Second generation antipsychotics, with the exception of olanzapine, are preferred first line. • Treatment should be continued for one year and reassessed after. • Supportive and solution oriented psychotherapy is beneficial. Prognosis About one third of the patients recover. The rest of the patients initially diagnosed with schizophreniform disorder progress to schizophrenia or schizoaﬀective disorder.23 2.6 Brief Psychotic Disorder Clinical Manifestations and Diagnosic Considerations Phenomenologically there is no diﬀerence between brief psychotic disorder (BPD), schizophreniform disorder, and schizophrenia. The diﬀerence between these three diag-noses is based on symptom duration. As indicated by its name, the duration of symptoms in BPD are brief: more than 1 day but less than 1 month. When the symptoms last longer than a month but less than 6 months the diagnosis changes to schizophreniform disorder. The psychotic symptoms should not be part of a pre-existing medical, drug induced, or primary psychiatric condition (including other psychotic or mood disorders). Subtypes/Specifiers DSM-IV-TR specifiers include: • With marked stressor(s) (brief reactive psychosis) • Without marked stressor(s) • With postpartum onset: when onset of symptoms is within 4 weeks postpartum25 Epidemiology Rare overall but more frequent in developing countries compared to developed countries.26 Treatment Considerations Hospitalization is recommended if the acute psychotic symptoms result in danger to self or others or significant impairment. Neuroleptics for short term treatment should be considered on a case by case basis. Prognosis By definition full remission of symptoms and return to prior level of functioning is expected within a month. 2.7 Schizoaﬀective Disorder Clinical Manifestations and Diagnostic Considerations The patient presents with symptoms of schizophrenia, mania, depression or a combination of mood and psychotic symptoms. The history is significant for at least one distinct episode of psychosis not overlapping with mood symptoms and a relative temporal predominance of mood symptoms. Diﬀerential diagnoses should include drug induced and medical conditions with secondary psychotic symptoms. While patients with schizophrenia can experience mood symptoms their duration is relatively short relative to the total duration of illness. When the psychotic symptoms represent a culmination of a severe mood episode a diagnosis of mood disorders (i.e., bipolar and major depression) with psychotic features should also be included in the diﬀerential. Epidemiology Unclear but possibly less common than schizophrenia.28 Treatment Considerations Hospitalization is recommended if the acute psychotic symptoms result in danger to self or others or significant impairment. Antipsychotics are recommended for acute psychotic symptoms. Second generation antipsy-chotics (SGA), excluding olanzepine, should be considered as first line. Mood stabilizers including lithium, valproic acid, and carbamazepine, or SGA are recommended for acute manic symptoms. A neuroleptic-mood stabilizer combination may work better than either agent alone, and augmenting a neuroleptic with lithium or valproic acid should be consid-ered as an augmentation strategy in cases of poor response to neuroleptic monotherapy. Antidepressants should be used conservatively for depressive symptoms. Close monitoring is required as an antidepressant can precipitate a manic switch in a patient with schizoaﬀective disorder. Prognosis Better than schizophrenia but not as good as mood disorders. Delusional Disorder Clinical Manifestations and Diagnostic Considerations The patient presents with non-bizarre delusional beliefs but most often the mental status examination is otherwise fairly normal. The delusional ideas are restricted to a specific subject and do not contaminate other mental processes. Other psychotic symptoms may include olfactory/gustatory hallucinations, which may be prominent and are closely related to the main delusional themes. If prominent auditory/visual hallucinations are present a diagnosis of schizophrenia rather than delusional disorder may be more appropriate. Associated symptoms are rare but may include mood or anxiety symptoms. When present, such symptoms are often secondary to the delusional beliefs (e.g., "of course I feel anxious with the NSA following me around the clock"). Other conditions (medical, drug induced, other primary psychiatric disorders, including other psychotic or mood disorders) cannot better explain the clinical picture. Subtypes/Specifiers • Erotomanic type: the patient erroneously believes that another person is in love with him/her • Grandiose type: the patient erroneously believes that he/she possesses enormous wealth, power, authority, knowledge, or has a special relationship to a deity or famous person • Jealous type: the patient erroneously believes that his/her partner is unfaithful • Persecutory type: the patient erroneously that he/she is targeted for punishment or retaliation • Somatic type: the patient erroneously believes that he/she has a medical condition or body deformity that is overlooked or misdiagnosed • Mixed type: delusions characteristic of more than one of the above types but without any one dominating theme • Unspecified type31 Epidemiology Rare. According to DSM-IV-TR estimated around 0.03% in the general population; 1-2% of all inpatient psychiatric admissions. The most common subtype is the persecutory type.32 Treatment Considerations Hospitalization is recommended if the acute psychotic symptoms result in danger to self or others or significant impairment. Prognosis Variable: the jealous type may wane and wax or remit; the persecutory type is often chronic.33 2.9 Shared Psychotic Disorder (Folie à Deux) Clinical Manifestations and Diagnostic Considerations Mental status examination is significant for non-bizarre delusions but otherwise is within normal limits. There are minimal associated mood or anxiety symptoms; if present such symptoms appear secondary to the tenaciously held delusional beliefs. History is significant for a close relationship with another person who presents with similar delusional beliefs. and meets criteria for a psychotic disorder. The patient who first presents with delusional symptoms is designated as the "primary," the "secondary" follows. Also, usually, the primary is dominant in his/her relationship with the secondary, who acts as a more passive recipient. For example, a parent with schizophrenia and chronic paranoid delusions about FBI surveillance may be the primary while his/her child, who only recently started to believe that indeed there are FBI cameras hidden on their property, is the secondary. Other diagnoses, including medical or drug induced disorders as well as other psychotic or mood disorders, should be excluded if folie à deux is to be diagnosed.34 Epidemiology Rare overall but statistics may be misleading due to under-reporting. Preliminary data suggest an increased prevalence in women.35 Treatment Considerations Hospitalization is recommended if the acute psychotic symptoms result in danger to self or others or significant impairment. Usually removing the secondary from the primary's environment is suﬃcient to promote complete remission of symptoms. In addition, the primary's condition should be treated as indicated. Interestingly, a remission of the primary's symptoms is followed by the remission of the secondary's delusional beliefs. Prognosis When the secondary is separated from the primary the prognosis is good.