Approach to schizophrenia spectrum and other psychotic disorders: Clinical sciences

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. 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. 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. 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. 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. 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.