AP
Unit-2
Schizophrenia is a serious mental illness characterized by incoherent or illogical
thoughts, bizarre behavior and speech, and delusions or hallucinations, such as hearing
voices. The age of onset is typically between the late teens and mid-30s. (APA)
DSM-5
A. Two (or more) of the following, each present for a significant portion of time during a
1-month period (or less if successfully treated). At least one of these must be (1), (2), or
(3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or
avolition).
B. For a significant portion of the time since the onset of the disturbance, level of
functioning in one or more major areas, such as work, interpersonal relations, or
self-care, is markedly below the level achieved prior to the onset (or when the onset is in
childhood or adolescence, there is failure to achieve expected level of interpersonal,
academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month
period must include at least 1 month of symptoms (or less if successfully treated) that
meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or
residual symptoms. During these prodromal or residual periods, the signs of the
disturbance may be manifested by only negative symptoms or by two or more
symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual
perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features
have been ruled out because either 1) no major depressive or manic episodes have
occurred concurrently with the active-phase symptoms, or 2) if mood episodes have
occurred during active-phase symptoms, they have been present for a minority of the
total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of
childhood onset, the additional diagnosis of schizophrenia is made only if prominent
delusions or hallucinations, in addition to the other required symptoms of
schizophrenia, are also present for at least 1 month (or less if successfully treated).
Subtypes
Disorganized schizophrenia is characterized by severe disruptions in thought
processes, leading to disorganized speech, unpredictable behavior, and inappropriate or
blunted emotional responses. Individuals with this form struggle with daily functioning,
often displaying fragmented thinking and difficulty maintaining coherent conversations.
Paranoid schizophrenia is primarily marked by strong delusions, often involving themes
of persecution or grandeur, along with auditory hallucinations. Unlike other forms,
cognitive abilities and speech may remain relatively intact, allowing individuals to
appear more functional despite their psychotic symptoms. However, heightened
suspicion and distrust of others can lead to social isolation and difficulty maintaining
relationships.
Catatonic schizophrenia involves extreme motor disturbances, ranging from complete
immobility and mutism to excessive, repetitive movements or bizarre postures. Some
individuals resist movement altogether (known as negativism), while others mimic
speech (echolalia) or actions (echopraxia). This form can be particularly severe,
requiring intensive medical intervention.
Undifferentiated schizophrenia is diagnosed when a person exhibits a mix of
symptoms from different subtypes without a dominant pattern. Individuals may
experience hallucinations, delusions, disorganized thinking, or catatonic behavior in
varying degrees. This category was used when symptoms did not fit neatly into one
specific subtype.
SYMPTOMS
● Positive symptoms are those that reflect an excess or distortion in a
normal repertoire of behavior and experience, such as delusions and
hallucinations.
● Negative symptoms, by contrast, reflect an absence or deficit of
behaviors that are normally present.
● Important negative symptoms in schizophrenia include flat affect, or
blunted emotional expressiveness, and alogia, which means very little
speech. Another negative symptoms is avolition, or the inability to initiate
or persist in goal-directed activities
Positive symptoms
Those that reflect an excess or distortion in a normal repertoire of behaviour and
experience.
Abnormally present
Positive symptoms
● Those that reflect an excess or distortion in a normal repertoire of behaviour and
experience.
● Abnormally present
Delusion
● Erroneous belief that is fixed and firmly held despite clear contradictory evidence.
● Latin verb “ludere” which means ‘to play’
● Tricks are played on the mind
● Delusion involves a disturbance in the content of thought.
Hallucination
● A sensory experience that occurs in the absence of any external perceptual
stimulus
● Auditory, visual, olfactory, tactile or gustatory
● Relevance for the patient at affective, conceptual or behavioural level
● Patients become emotionally involved in their hallucinations, often incorporating
them into their delusions.
● Hallucinations are perception-like experiences that occur without an external
stimulus.
● They are vivid and clear, with the full force and impact of normal perceptions, and
not under voluntary control.
● They may occur in any sensory modality, but auditory hallucinations are the most
common in schizophrenia and related disorders.
● Auditory hallucinations are usually experienced as voices, whether familiar or
unfamiliar, that are perceived as distinct from the individual’s own thoughts.
● The hallucinations must occur in the context of a clear sensorium; those that
occur while falling asleep (hypnagogic) or waking up (hypnopompic) are
considered to be within the range of normal experience.
● Hallucinations may be a normal part of religious experience in certain cultural
contexts.
Negative symptoms
● Absence or deficit of behaviours that are normally present
● Abnormally absent
Negative symptoms account for a substantial portion of the morbidity associated with
schizophrenia but are less prominent in other psychotic disorders. Two negative
symptoms are particularly prominent in schizophrenia: diminished emotional
expression and avolition. Diminished emotional expression includes reductions in the
expression of emotions in the face, eye contact, intonation of speech (prosody), and
movements of the hand, head, and face that normally give an emotional emphasis to
speech. Avolition is a decrease in motivated self-initiated purposeful activities. The
individual may sit for long periods of time and show little interest in participating in
work or social activities. Other negative symptoms include alogia, anhedonia, and
asociality. Alogia is manifested by diminished speech output. Anhedonia is the
decreased ability to experience pleasure from positive stimuli or a degradation in the
recollection of pleasure previously experienced. Asociality refers to the apparent lack of
interest in social interactions and may be associated with avolition, but it can also be a
manifestation of limited opportunities for social interactions.
Etiology (Causes Schizophrenia)
The exact cause of schizophrenia isn’t known. But like cancer and diabetes,
schizophrenia is a real illness with a biological basis. Researchers have uncovered a
number of things that appear to make someone more likely to get schizophrenia,
including:
● Genetics (heredity): Schizophrenia can run in families, which means a greater
likelihood to have schizophrenia may be passed on from parents to their children.
● Brain chemistry and circuits: People with schizophrenia may not be able to
regulate brain chemicals called neurotransmitters that control certain pathways,
or "circuits," of nerve cells that affect thinking and behavior.
● Brain abnormality: Research has found abnormal brain structure in people with
schizophrenia. But this doesn’t apply to all people with schizophrenia. It can
affect people without the disease.
● Environment: Things like viral infections, exposure to toxins like marijuana, or
highly stressful situations may trigger schizophrenia in people whose genes
make them more likely to get the disorder. Schizophrenia more often surfaces
when the body is having hormonal and physical changes, like those that happen
during the teen and young adult years.
There’s no one single cause of schizophrenia. Experts suspect schizophrenia happens
for different reasons. The three main reasons include:
● Imbalances in chemical signals your brain uses for cell-to-cell communication.
● Brain development problems before birth.
● Loss of connections between different areas of your brain.
What are the risk factors of schizophrenia?
While there aren’t any confirmed causes of schizophrenia, there are risk factors for
developing the condition:
● Environment: Many factors in the world around you can increase your risk of
developing schizophrenia. Being born during the winter increases your risk
slightly. Certain illnesses that affect your brain, including infections and
autoimmune diseases (where your immune system attacks part of your body),
can also increase your risk. Extreme stress for long periods can also play a role in
developing it.
● Development and birth circumstances: How you developed before you were born
plays a role in schizophrenia. The risk of having schizophrenia goes up if your
birthing parent had gestational diabetes, preeclampsia, malnutrition or a vitamin
D deficiency while pregnant with you. The risk also increases if you were
underweight at birth or if there were complications during your birth (like if you
were born via an emergency cesarean section).
● Recreational drug use: Schizophrenia is linked with the use of certain recreational
drugs, especially in larger amounts and earlier in life. The connection between
heavy marijuana (cannabis) use as a teenager is one of the best-studied of these
links. But experts aren’t sure if marijuana use is a direct cause of schizophrenia
or if it’s just a contributing factor.
Is schizophrenia genetic?
Experts haven’t found one specific cause of schizophrenia, so they can’t say for sure if
genetics cause schizophrenia. But if you have a family history of schizophrenia —
especially a parent or sibling with it — you have a much higher risk of developing this
condition.
TREATMENT
Pharmacological Treatment
The first drug to be used with beneficial effect in schizophrenia was reserpine, in India
by Sen and Bose (1931). Reserpine is no longer used for the treatment of schizophrenia
for a variety of reasons, including its propensity to cause severe and suicidal
depression.
Antipsychotics were formally discovered by Delay and Deniker in 1952. Since their
introduction, they have changed the outcome of schizophrenia significantly.
Atypical (or the second generation) antipsychotic drugs, such as risperidone,
olanzapine, quetiapine, are more commonly used.
Clozapine, another antipsychotic, is available in the Indian market. The clinical trials
have shown that clozapine is effective in about 30% of patients who had no beneficial
response to traditional antipsychotics.
Electroconvulsive Therapy (ECT)
Schizophrenia is not a primary indication for ECT. The indications for ECT in
schizophrenia include:
1. Catatonic stupor.
2. Uncontrolled catatonic excitement.
3. Acute exacerbation not controlled with drugs.
4. Severe side-effects with drugs, in presence of untreated schizophrenia.
Usually 8-12 ECTs are needed (although up to 18 have been given in poor responders),
administered two or three times a week.
Psychosocial Treatment
Psychoeducation of the patient and especially the family/care givers (with patient’s
consent. Psychoeducation helps in establishing a good therapeutic relationship with the
patient (and the family). Psychoeducation also involves explaining the
stress-vulnerability model of schizophrenia to the patient and care givers.
Group psychotherapy is particularly aimed at teaching problem solving and
communication skills. This can be conducted in a form which is known as the ‘ social
skills training package’.
Family therapy: Apart from psychoeducation, family members are also provided social
skills training to enhance communication and help decrease intra-familial ‘tensions’.
Attempts are also made to decrease the ‘ expressed emotions’ of ‘significant others’ in
the family. The family members’ awareness is raised regarding decreasing expectations
and avoiding critical remarks, emotional over-involvement, and hostility.
Psychosocial rehabilitation is used. This includes activity therapy, to develop the work
habit, training in a new vocation or retraining in a previous skill, vocational guidance, in
dependent job placement, sheltered employment or self-employment, and occupational
therapy.
Assessment:
● Structured Clinical Interview for DSM-5 (SCID-5) – Helps in diagnosing
schizophrenia and other psychiatric disorders based on DSM-5 criteria.
● Comprehensive Assessment of Symptoms and History (CASH) – Assesses the
full range of psychotic symptoms and patient history.
● Positive and Negative Syndrome Scale (PANSS) – Measures positive symptoms
(hallucinations, delusions), negative symptoms (social withdrawal, lack of
motivation), and general psychopathology.
● Scale for the Assessment of Positive Symptoms (SAPS) – Specifically assesses
hallucinations, delusions, and thought disorders.
● Scale for the Assessment of Negative Symptoms (SANS) – Evaluates negative
symptoms like blunted affect, social withdrawal, and poverty of speech.
● Brief Psychiatric Rating Scale (BPRS) – Measures overall psychiatric symptoms,
including psychosis and mood disturbances.
● MATRICS Consensus Cognitive Battery (MCCB) – Assesses cognitive deficits in
schizophrenia (attention, memory, executive function).
DELUSIONAL DISORDERS
Delusional disorder is a psychotic disorder that can make it hard for a person to
distinguish between what’s real and what’s imagined to be true.1 The primary symptom
of this condition is the presence of delusions, which are irrational, unshakeable beliefs
that are untrue. (APA)
DSM-5
A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A for schizophrenia has never been met.
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not
markedly impaired, and behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief relative
to the duration of the delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance or
another medical condition and is not better explained by another mental disorder, such
as body dysmorphic disorder or obsessive-compulsive disorder.
There are four types of delusions outlined in the DSM-5:
● Bizarre delusions are implausible or impossible, such as being abducted by
aliens.
include beliefs that are impossible in our reality, such as believing someone has
removed an organ from your body without any physical evidence of the
procedure.
● Non-bizarre delusions could occur in reality, such as being cheated on, poisoned,
or stalked by an ex-partner.
People with delusional disorder often experience non-bizarre delusions.
Non-bizarre delusions involve situations that could possibly occur in real life,
such as being followed, deceived or loved from a distance. These delusions
usually involve the misinterpretation of perceptions or experiences. In reality,
these situations are either untrue or are highly exaggerated.
● Mood-congruent delusions are consistent with a depressive or manic state, such
as delusions of abandonment or persecution when depressed, and delusions of
superiority or fame when manic.
● Mood-incongruent delusions are not affected by the particular mood state. They
may include delusions of nihilism (e.g., the world is ending) and delusions of
control (e.g., an external force controls your thoughts or movements).
SUBTYPES
• Erotomanic: People with this type of delusional disorder believe that another
person, often someone important or famous, is in love with them. They may
attempt to contact the person of the delusion and engage in stalking
behavior.
• Grandiose: People with this type of delusional disorder have an overinflated
sense of self-worth, power, knowledge or identity. They may believe they have
a great talent or have made an important discovery.
• Jealous: People with this type of delusional disorder believe that their spouse
or sexual partner is unfaithful without any concrete evidence.
• Persecutory: People with this type of delusional disorder believe someone or
something is mistreating, spying on or attempting to harm them (or someone
close to them). People with this type of delusional disorder may make
repeated complaints to legal authorities.
• Somatic: People with this type of delusional disorder believe that they have a
physical issue or medical problem, such as a parasite or a bad odor.
• Mixed: People with this type of delusional disorder have two or more of the
types of delusions listed above.
ETIOLOGY(causes)
Delusional Disorder (DD) is a psychotic disorder characterized by the presence of one or
more delusions lasting at least one month without significant impairment in daily
functioning. Its exact cause is unknown, but several factors contribute to its
development:
● Biological Factors
Genetic predisposition: Family history of schizophrenia or psychotic disorders
increases the risk.
Neurotransmitter abnormalities: Dopaminergic dysfunction, particularly
hyperactivity in the mesolimbic pathway, is implicated.
Structural brain abnormalities: Abnormalities in the limbic system, basal ganglia,
and prefrontal cortex may play a role.
● Psychological Factors
Cognitive biases: Individuals may have an impaired ability to assess reality and
interpret events logically.
Personality traits: Paranoid, schizotypal, or obsessive-compulsive personality
traits may contribute to DD.
● Environmental & Social Factors
Social isolation: Lack of social interactions can reinforce delusional thinking.
Stressful life events: Trauma, migration, or financial difficulties may trigger
delusions.
Substance use: Stimulants like amphetamines or cannabis can exacerbate
symptoms.
Pharmacological Treatment
Antipsychotics (First-line)
1. Atypical (Second-generation) antipsychotics:
i. Risperidone (2–6 mg/day)
ii. Olanzapine (5–20 mg/day)
iii. Aripiprazole (10–30 mg/day)
iv. Quetiapine (50–800 mg/day)
2. Typical (First-generation) antipsychotics:
i. Haloperidol (1–10 mg/day)
Adjunctive Medications
a. Antidepressants (e.g., SSRIs like fluoxetine, sertraline) for comorbid
depression or anxiety
b. Mood stabilizers (e.g., lithium, valproate) if there are affective symptoms
Non-Pharmacological Treatment
Cognitive Behavioural Therapy (CBT)
● Helps challenge and modify delusional beliefs
● Improves insight and coping strategies
Supportive Psychotherapy
● Provides emotional support and reassurance
● Enhances social functioning
Family Therapy
● Educates family members about the disorder
● Helps manage conflicts and misunderstandings
Social Skills Training
● Encourages engagement in social activities
● Reduces isolation and withdrawal
ASSESSMENTS
● Peters et al. Delusions Inventory (PDI-21) – A self-report questionnaire
measuring the intensity, preoccupation, and distress associated with delusions.
● Brown Assessment of Beliefs Scale (BABS) – Evaluates the degree of insight
into delusional beliefs.
● Delusions Symptom States Inventory (DSSI) – Measures different types of
delusional thinking.
● Brief Psychiatric Rating Scale (BPRS) – Assesses overall psychiatric symptoms,
including delusions, hallucinations, and mood disturbances.
ACUTE AND TRANSIENT PSYCHOTIC DISORDER (ATPD)
Acute and Transient Psychotic Disorder (ATPD) is a brief psychotic episode
characterized by a sudden onset of delusions, hallucinations, disorganized thinking,
and/or catatonia that typically resolves within one to three months without residual
impairment. It is classified under ICD-10 and ICD-11 and is similar to Brief Psychotic
Disorder (BPD) in DSM-5 but has distinct diagnostic criteria.