TABLE 164 Psychotic Disorders

Psychotic disorders involve grossly impaired reality testing. Specific diagnoses depend on the nature and duration of the symptoms and on a cause when it can be identified. Seven disorders are outlined below.

Schizophrenia

Schizophreniform Disorder

Schizoaffective Disorder

Delusional Disorder

Brief Psychotic Disorder

Psychotic Disorder Due to a General Medical Condition

Substance-Induced Psychotic Disorder

Schizophrenia impairs major functioning, as at work or school or in interpersonal relations or self care. For this diagnosis, performance of one or more of these functions must have decreased for a significant time to a level markedly below prior achievement. In addition, the person must manifest at least two of the following for a significant part of 1 month: (1) delusions, (2) hallucinations, (3) disorganized speech, (4) grossly disorganized or catatonic behavior,* and (5) negative symptoms such as a flat affect, alogia (lack of content in speech), or avolition (lack of interest, drive, and ability to set and pursue goals). Continuous signs of the disturbance must persist for at least 6 months.

Subtypes of this disorder include paranoid, disorganized, and catatonic schizophrenia.

A schizophreniform disorder has symptoms similar to those of schizophrenia but they last less than 6 months, and the functional impairment seen in schizophrenia need not be present.

A schizoaffective disorder has features of both a major mood disturbance and schizophrenia. The mood disturbance (depressive, manic, or mixed) is present during most of the illness and must, for a time, be concurrent with symptoms of schizophrenia (listed above). During the same period of time, there must also be delusions or hallucinations for at least 2 weeks without prominent mood symptoms.

A delusional disorder is characterized by nonbizarre delusions that involve situations in real life, such as having a disease or being deceived by a lover. The delusion has persisted for at least a month, but the person's functioning is not markedly impaired and behavior is not obviously odd or bizarre. The symptoms of schizophrenia except for tactile and olfactory hallucinations related to the delusion have not been present.

In this disorder, at least one of the following psychotic symptoms must be present: delusions, hallucinations, disordered speech such as frequent derailment or incoherence, or grossly disorganized or catatonic behavior. The disturbance lasts at least 1 day but less than 1 month, and the person returns to his or her prior functional level.

Prominent hallucinations or delusions may be experienced during a medical illness. For this diagnosis, they should not occur exclusively during the course of delirium. The medical condition should be documented and judged to be causally related to the symptoms.

Prominent hallucinations or delusions may be induced by intoxication or withdrawal from a substance such as alcohol, cocaine, or opioids. For this diagnosis, these symptoms should not occur exclusively during the course of delirium. The substance should be judged to be causally related to the symptoms.

*Catatonic behaviors are psychomotor abnormalities that include stupor, mutism, negativistic resistance to instructions or attempts to move the person, rigid or bizarre postures, and excited, apparently purposeless activity.

TABLE 16-5 ■ Delirium and Dementia

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