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Schizophrenia Spectrum and other Psychotic Disorders

What are Schizophrenia Spectrum and other Psychotic Disorders?

Schizophrenia is now understood as a spectrum disorder, which means it is on a continuum and shares the spectrum with other related psychotic disorders. Specifically, schizophrenia is a spectrum or range of conditions that include psychotic symptoms. The hallmark trait of each of these disorders is the experienced disconnection from reality. The disconnections may take different forms and will present differently depending on the specific disorder. 

The disorder does not discriminate between sexes, race, or ethnicities. Schizophrenia spectrum and other psychotic disorders can significantly disrupt your level of functioning in your day-to-day. Some of these conditions may cause substantial impairment in occupational, academic, social, and other important settings. Specifically with schizophrenia, your thoughts, perceptions, and reality may be severely distorted or disorganized, which impacts not only your mental well-being, but also your physical health.

There are several conditions on the schizophrenia spectrum and other psychotic disorders. These include:

  • Delusional disorder. There are 7 types of delusions (erotomaniac, grandiose, jealous, persecutory, somatic, mixed, and unspecified). There must be a presence of 1 or more delusions for a period of 1 month of longer.
  • Brief psychotic disorder. There must be a presence of one or more of symptoms, including, delusions, hallucinations, disorganized speech, significantly disorganized or catatonic behavior.
  • Schizophreniform disorder. Two or more symptoms, including delusions, hallucinations, disorganized speech, significantly disorganized or catatonic behavior, and diminished emotional expression must be present for a substantial portion of a 1-month period (or less if successfully treated). Schizoaffective disorder, depressive or bipolar disorder with psychotic features have been ruled out.
  • Schizophrenia. Two or more symptoms, including delusions, hallucinations, disorganized speech, significantly disorganized or catatonic behavior, and diminished emotional expression must be present for a substantial portion of a 1-month period (or less if successfully treated). At least 1 of the symptoms need to be delusions, hallucinations, or disorganized speech. For a substantial portion of time since onset of the disturbance, normal daily functioning in one major area, such as occupational settings, academic settings, interpersonal relationships, and self-care is significantly low compared to before the onset of the disturbance. Continuous signs of the disturbance must persist for a 6-month period.
  • Schizoaffective disorder. There is an uninterrupted period of illness during which there is a major mood episode (major depressive or manic), concurrent with two or more specific symptoms of schizophrenia (delusions, hallucinations, disorganized speech, significantly disorganized or catatonic behavior, or diminished emotional expression).
  • Substance/medication-induced psychotic disorder. In this disorder, there must be a presence of delusions, hallucinations, or a combination of both. There must be evidence that the disturbance occurred during or soon after substance intoxication or withdrawal, or after exposure to a medication. Additionally, the substance or medication must be capable of causing delusions or hallucinations. It must cause clinically significant impairment or distress in occupational, social, academic, or other important areas of functioning.
  • Psychotic disorder due to another medical condition. There must be prominent hallucinations or delusions. There is confirming evidence from the medical history, physical exam, and lab findings that the disturbance is the direct pathophysiological consequence of another medical condition.
  • Catatonia. The clinical picture must present with 3 or more symptoms, including, stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, or echopraxia.

Symptoms

Schizophrenia spectrum and other psychotic disorders tend to have similar or overlapping symptoms. Specific symptoms are dependent on the disorder. More specifically, schizophrenia, usually happens in 3 stages, and will have different types or degrees of systems in each stage. 

  • Onset (prodrome). This is the beginning stage of schizophrenia. Presenting symptoms in this stage may indicate a trajectory toward more severe symptoms. Symptoms during the onset may include anxiety, social withdrawal, neglect of self-care or personal hygiene, and lack of motivation.
  • Active. In this stage, symptoms are at their most severe. Typically, a person in this stage disconnects from reality and symptoms cause significant distress or impairment in their daily living. Active stage symptoms include delusions, hallucinations, disorganized or incoherent speaking, disorganized or unusual movements, and negative symptoms.
  • Residual. In this stage, people may still have some ongoing symptoms of schizophrenia, but they are not as severe and do not necessarily impact daily functioning or living. Some of the most noticeable symptoms in the residual stage are odd beliefs, lack of motivation, decreased feelings of enjoyment or pleasure, limited speaking, and decreased emotional expression. Some people in this stage improve to a level of functioning that feels normal or fully recovered. However, this stage is temporary, and eventually the person will cycle back through the prodrome and active stages. 

Other symptoms may include:

  • Frequently feeling paranoid, suspicious, or afraid
  • Lack of insight (anosognosia)
  • Neglecting personal hygiene and appearance
  • Depression and anxiety
  • Suicidal thoughts
  • Substance abuse, used to self-medicate

Schizophrenia can be difficult to treat, in large part due to the lack of insight many people with schizophrenia have. Often, people with schizophrenia do not have an awareness or level of insight (anosognosia) to recognize they are exhibiting any of the symptoms. Sometimes this lack of insight works to fuel the paranoia and delusion that people are trying to hurt them.

If you or your loved one is experiencing symptoms of schizophrenia or other related psychotic disorders, please consult with your primary care provider or mental health provider.

Causes

There is no singular cause of schizophrenia, and it often develops from several contributing factors. However, it is not necessarily guaranteed that you will develop schizophrenia if you happen to have any of these factors. The three main contributing factors include:

  • Brain chemistry. Problems or imbalances with neurotransmitters (the brains way to communicate), a loss of connection between parts of the brain, and having brain development problems at birth, can lead to the development of schizophrenia. 
  • Genetics. Having a family history of schizophrenia may increase your risk of developing the disorder. Additionally, brain-imaging tests indicate differences within the brain structure and central nervous system in people with schizophrenia.
  • Environmental factors. Factors, such as childhood trauma or chronic or acute stress in childhood may contribute to developing schizophrenia.

Risk Factors

There are several risk factors for developing schizophrenia. Risk factors include:

  • Family history of schizophrenia spectrum or other psychotic disorders
  • Certain infections and autoimmune disorders that affect parts of the brain
  • Development and birth circumstances (if the mother had gestational diabetes, preeclampsia, vitamin D deficiency, low birthweight, or other complications at birth, such as cesarean section) 
  • Recreational drug use, especially larger amounts in teenage and young adult years (marijuana use has been specifically studied, and can be a contributing factor)

Complications

If schizophrenia is left untreated, it can lead to several complications. Complications include:

  • Suicidal thinking, attempts, or completion
  • Depression
  • Anxiety
  • OCD and related disorders
  • Substance abuse
  • Academic problems
  • Inability to work
  • Social withdrawal or social isolation
  • Medical problems
  • Being stigmatized or mistreated
  • Aggressive behavior (although less common)

Diagnosis

To make a diagnosis, your doctor will want to rule out any other medical conditions and will refer you to a mental health provider. Diagnostic tools include:

  • Physical exam. A doctor will conduct a physical exam, which also includes taking a full medical history and asking questions regarding family history of mental health issues.
  • Tests and screenings. Your doctor or mental health provider may request specific tests, screenings, or assessments to rule out other conditions, mental health disorders, or substance use. Additionally, your doctor may recommend brain-imaging tests.
  • Psychological evaluation. Your mental health provider will take a thorough intake, gathering information about presenting problems, symptoms, family and social history, substance use, medical history, and mental health history. In addition to the intake, your mental health provider may provide other screenings and assessments to rule out or screen for specific conditions or disorders. It may take 1-3 (sometimes more) sessions to make an appropriate diagnosis.  

Treatment

Although schizophrenia is not a curable disease, there are many ways to effectively reduce and manage symptoms of the disorder. Many people with schizophrenia, if appropriately treated, can live happy and healthy lives. Some people with schizophrenia may enter a period with no symptoms, and doctors refer to this period as “remission” and not “cured,” since no one can predict if and when another onset of active symptoms will occur in the future. 

The most effective treatments seem to be a combination of medication, psychotherapy, and self-management techniques. Because people with schizophrenia lack insight, it is common for patients to be resistant to treatment. Adherence to treatment is one of the best indicators for treatment outcomes. Specifically, treatments include:

  • Medication. The most common and effective medications used to treat schizophrenia are first-generation and second-generation antipsychotics. The difference between the medications is that first-generation antipsychotics block how your brain uses dopamine. Second-generation antipsychotics block how your brain uses dopamine and serotonin. Medications can be given in pill form, with some antipsychotics also being offered as injections. Injections can be a great option for treatment-resistant patients, or patients who struggle to adhere to treatment. Consult with your doctor or psychiatrist to discuss what medications may work best for you.

  • Psychotherapy. Various modalities can be effective in the treatment of schizophrenia. However, one of the greatest factors in treatment outcomes is adherence to treatment. Often, patients with schizophrenia are resistant to treatment because they lack insight and may not be aware they have a problem. Cognitive behavioral therapy is an evidenced-based therapy that has shown to be effective in treating schizophrenia. Individual therapy seeks to identify distorted thought patterns, perceptions, and beliefs and replace with more adaptive ones. Additionally, part of therapy may be devoted to building social skills, improving personal-hygiene, and improving self-regulation skills. Family therapy, vocational rehabilitation, and supported employment may also be recommended.
  • Hospitalization. In more severe cases, hospitalization may be necessary. Generally, patients may need to be hospitalized when they plan or attempt to harm themselves or others, significantly struggle with proper nutrition, getting adequate sleep, or basic hygiene.
  • Electroconvulsive therapy. This may be a viable option for patients who do not seem to respond to medications or traditional psychotherapy. It may be especially helpful for patients who also struggle with depression.