Approach to schizophrenia spectrum and other psychotic disorders: Clinical sciences

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Introduction 0:00–1:02

Schizophrenia spectrum and other psychotic disorders are psychiatric conditions characterized by psychotic symptoms, such as delusions, hallucinations, disorganized speech, and disorganized behavior.
These disorders are considered a spectrum because the severity and combination of symptoms can vary greatly among patients.
Schizophrenia is the primary condition in this group, along with related disorders such as schizophreniform disorder and brief psychotic disorder, which present with similar but shorter and milder symptoms.
Additionally, mood symptoms can occur alongside psychotic symptoms in conditions like schizoaffective disorder. Finally, psychotic symptoms can also be present in delusional disorders and certain cluster A personality disorders.
Now, when a patient presents with a chief concern suggesting a schizophrenia spectrum or other psychotic disorder, start with a focused history and physical examination.

H&P 1:02–3:24

Your patient may present with delusions, hallucinations, disorganized speech, or disorganized behavior. Now, to break it down really quick, delusions are fixed, false beliefs classified as bizarre or non-bizarre based on their plausibility.
For example, a belief that aliens are controlling one's mind is considered bizarre, while believing that the police are tracking a person is non-bizarre.
On the other hand, hallucinations are false sensory experiences, most commonly auditory, like hearing familiar or unfamiliar voices, sounds, or commands.
Other types of hallucinations are visual, tactile, olfactory, or gustatory. Next, disorganized speech may manifest as loosely connected topics or answers that are unrelated to the questions asked.
In severe cases, speech can become a jumble of words, known as word salad, resembling aphasia. Some patients might present with echolalia, which is the meaningless repetition of words just spoken by another person; while others may speak in a sing-song or rhyming manner, known as clang.
Finally, disorganized behavior can vary from impulsive agitation to stereotyped movements and catatonia. Stereotyped movements can manifest as repetitive, functionless behaviors like body rocking or foot tapping, while catatonia refers to a severe type of disorganized behavior, which can range from strange movements like waxy flexibility, to lack of movements like mutism or negativism, to catatonic excitement, which is characterized by excessive movement.
With these findings, consider schizophrenia spectrum disorders or other psychotic disorders. Next, assess the key features that will help you differentiate between the causes.

Assess for key features 3:24–6:10

If your patient has one or more symptoms, including delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms; or if they report a decline in functioning, your next step is to initiate a medical work-up to rule out physical conditions that can cause psychosis.
Now, here’s your first clinical pearl! Your patient will report one or more psychotic symptoms, which might be positive or negative in nature.
Positive symptoms are experiences present in the affected patient but not in the general population. These include delusions, hallucinations, and disorganized speech or behavior.
Negative symptoms, on the other hand, are experiences that are absent in the patient but present in the general population.
So instead of social engagement, motivation, and goal-directed activity normally found in the general population, the patient will demonstrate social withdrawal, decreased motivation, and lack of affect.
The work-up will depend on your history and exam findings. Labs typically include a CBC, to screen for infection; complete metabolic panel or CMP to screen for electrolyte abnormalities, especially hypercalcemia which might suggest hyperparathyroidism; ammonia to screen for hepatic encephalopathy; heavy metal testing to rule out heavy metal poisoning; thyroid stimulating hormone to screen for hyperthyroidism; rapid protein reagin or RPR to screen for syphilis; and urine drug screen to evaluate for substance use.
Additionally, consider ordering a Lyme titer if the patient was recently exposed to ticks, and urine metanephrines to screen for pheochromocytoma if the patient has extremely elevated blood pressure and heart rate.
Finally, order a head CT to screen for an intracranial tumor, and consider ordering a brain MRI, electroencephalogram, or lumbar puncture for further evaluation, especially if this is your patient’s first psychotic episode.
If any of the work-up shows abnormal results, consider an alternative diagnosis. However, if the results are within normal limits, your next step is to assess for the presence of a mood episode, like mania or a major depressive episode.

Assess for mood episode: Absent 6:10–6:29

If these are absent, assess for the approximate timing of the onset of the psychotic symptoms. If the onset of psychotic symptoms was six or more months ago, consider schizophrenia.

Schizophrenia 6:29–7:41

Your next step is to assess the DSM-5 diagnostic criteria. To meet the criteria, your patient must experience two or more of the following characteristic symptoms for a significant portion of time during a one-month period: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms.
Moreover, at least one of these symptoms must be either delusions, hallucinations, or disorganized speech. In addition, your patient must demonstrate an impairment in functioning in areas such as work, relationships with others, or self-care for a significant portion of time since the onset of symptoms.
If these criteria are met, diagnose schizophrenia. Here’s a high-yield fact!
Schizophrenia exists across genders and races, and most commonly emerges in late teenage years or early twenties. If the onset of your patient’s psychotic symptoms began one to six months ago, consider schizophreniform disorder.

Schizophreniform 7:41–9:03

Next, assess the DSM-5 diagnostic criteria. The criteria are the same as those for schizophrenia, except symptoms must be present for one month but less than six months.
So, your patient must experience two or more of the following characteristic symptoms: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms; and at least one of these symptoms must be either delusions, hallucinations, or disorganized speech.
In addition, there’s is no requirement for impaired functioning. If these conditions are met, diagnose schizophreniform disorder.
Here’s another clinical pearl you should keep in mind! If the patient’s symptoms remit prior to 6 months, schizophreniform might be the final diagnosis.
However, often this condition develops into schizophrenia or schizoaffective disorder. If diagnosed before symptoms resolve, schizophreniform is considered a provisional diagnosis.
Next, if the first onset of your patient’s psychotic symptoms was less than one month ago, consider brief psychotic disorder.

Brief psychotic disorder 9:03–10:19

Then, assess the DSM-5 criteria. Here, one or more of the following symptoms must be present: delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior; and at least one of these symptoms must be either delusions, hallucinations, or disorganized speech.
Now, what sets brief psychotic disorder apart from schizophrenia is that these symptoms should last longer than one day, but less than one month.
Additionally, your patient must fully return to premorbid level of function after the episode. If these criteria are met, diagnose brief psychotic disorder.
Here’s a clinical pearl to keep in mind! It’s especially important to rule out other causes of brief psychotic symptoms, since many medical conditions can mimic brief psychotic disorder, like delirium or substance use.
Alright, let’s now switch gears and look at when a mood episode is present. In this case, your next step is to assess the timeline of symptoms.

Mood episode present 10:19–10:29

If your assessment reveals that your patient only has psychotic symptoms during mood episodes, and psychotic symptoms resolve when the mood episode resolves, consider an alternative diagnosis such as mood disorder with psychotic features.

Alternative diagnosis 10:29–10:46

On the other hand, if a mood episode occurs during ongoing psychotic symptoms, consider schizoaffective disorder and assess the DSM-5 criteria.

Schizoaffective disorder 10:46–12:19

To meet the criteria, your patient must experience a major depressive or manic episode during an uninterrupted period of psychosis with two or more psychotic symptoms, including delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior; and at least one of these symptoms must be either delusions, hallucinations, or disorganized speech.
Your patient must also experience these psychotic symptoms for at least two weeks without the presence of a mood episode, and mood episodes must be recurrent.
If your patient meets these criteria, diagnose schizoaffective disorder. Here’s a clinical pearl!
The type of schizoaffective disorder diagnosed depends on the type of mood episodes present. If the patient experiences only major depressive episodes, they are diagnosed with schizoaffective disorder, depressed type.
If the patient experiences only manic episodes, or both depressive and manic episodes, diagnose schizoaffective disorder, bipolar type, instead.
Let’s switch gears and look at psychotic features in disorders where your patient only reports delusions with no functional impairment.

Delusional disorder 12:19–13:20

Delusional disorder is a condition in which a patient chronically believes something false. If this is the case, consider delusional disorder.
Next, assess the DSM-5 criteria. To meet the criteria, your patient must have one or more delusions which must be present for at least one month, and your patient does not meet the diagnostic criteria for schizophrenia.
And, although the delusion and its ramifications may have some impact on the patient’s daily life, the delusion isn’t bizarre, the patient doesn’t appear especially odd, and their functioning is not significantly impaired.
Lastly, if manic or depressive episodes occur, they last only a short period of time. Lastly, let’s discuss cluster A personality disorder.

Cluster A Personality Disorder 13:20–14:18

Your patient may experience mild hallucinations or delusions that occur intermittently, without a significant decline in functioning.
If your patient has these symptoms, they might have a cluster A personality disorder, which includes schizotypal, schizoid, and paranoid disorders.
And here’s a high yield fact! The symptoms of cluster A personality disorder typically appear when a patient is under severe stress, particularly in schizotypal personality disorder.
However, the psychotic symptoms are not accompanied by grossly disorganized speech, thought, or behavior, nor do they involve cognitive decline.
More importantly, these symptoms tend to remit after a brief period. Alright, as a quick recap...

Review 14:18–15:32

Schizophrenia spectrum and other psychotic disorders are conditions that can present with delusions, hallucinations, disorganized speech, disorganized behavior, or negative symptoms.
The medical work-up for psychosis is extensive, especially for a first psychotic episode, since many physical conditions can produce psychotic symptoms.
Major schizophrenia spectrum and other psychotic disorders include schizophrenia, a chronic condition marked by multiple psychotic symptoms and an impairment in functioning; schizophreniform disorder, which has the same symptoms as schizophrenia but with no impairment in functioning; and brief psychotic disorder, which involves similar symptoms as schizophrenia but for a shorter duration.
There is also schizoaffective disorder, which involves both psychosis and mood episodes; and delusional disorder, which presents with delusions only, without hallucinations or disorganization.
Finally, cluster A personality disorders can