Psychosis Differential

Psychosis Differential is a study note in Psychotic Disorders.

Psychosis DDX

(Secondary Psychotic Illnesses)

  • Manic Episode with Psychotic Features
  • Major Depressive Episode with Psychotic Features

(Other)

  • Catatonia
  • Other specified schizophrenia spectrum and other psychotic disorder
  • Unspecified schizophrenia spectrum and other psychotic disorder

Criteria Comparison

SymptomsTimeframeBaselineTypes
1o Psychotic Illnesses
Brief Psychotic D/O>1 of…DelusionsHallucinationsSudden onset
1 day – 1m		Return to premorbid functionBIPS
Post-Partum Psychosis
Disorganized speech
Schizophreniform D/O>2 of…DelusionsHallucinations1mo – 6moGood prognosis
Poor prognosis
Disorganized speech
Disorganized behavior
(-) Sx
Schizophrenia(A) Acute: >2 (+) / (-) symptoms
(C) Residual signs
    • (-) sx, attenuated (+) sx
>1mo
>6mo		↓ level of function
Schizoaffective D/O- Mood episode AND >2 (+)/(-) sx
Mood sx present for majority of illness
Depends on mood		>2 weeks of
SCZ sx
w/o mood criteria
Psychotic-like Illnesses
Delusional D/ODelusions
NO bizarre behavior
NO func. impairment		>1moParaphrenia (elderly)
2o Psychotic Illnesses
Substance/Med induced Psychotic D/O- Delusions OR Hallucinations
- evidence of substance/med exposure		<1mo from intoxication / withdrawal
Psychotic D/O due to AMC

DSM

  • At least 1 of…
  • Delusions |
  • Hallucinations | - at least one must be 1, 2 or 3
  • Disorganized speech|
  • Grossly disorganized / catatonic behavior
  • Duration lasting between 1 day – 1 month, with eventual return to premorbid function
  • Not better explained by MDD or BPD with psychotic features, or another psychotic disorder
  • Not attributable to physiological effects of substance or AMC

Specifiers

  • Type
  • … with marked stressor: in response to events stressful to anyone in that culture
  • AKA: Brief Reactive Psychosis
  • … without marked stressor:not in response to stressful events
  • ... with postpartum onset:onset during pregnancy or w/ i 4 weeks post-partum
  • ... with catatonia
  • Severity
  • … current severity mild/moderate/severe

B) SCHIZOPHRENIFORM DISORDER

DSM - Criteria

  • >2 psychotic symptoms of…
    • Delusions
    • Hallucinations
    • Disorganized speech
At least one must be 1, 2, or 3Present for significant portion of time during a 1-month period
    • Grossly disorganized / catatonic behavior
    • Negative symptoms
  • Episode lasts between 1 – 6 months.
  • Schizoaffective, depressive, and bipolar disorders with psychotic features ruled out by…
  • No depressive or manic episodes occurring concurrently with active Sx
  • OR Mood episodes occur during active symptoms, but present for a minority of total duration of sx
  • Not attributable to physiological effects of substance or medical condition

Specifiers

  • Type
  • … with good prognostic features: with >2 of…
  • Onset of psychotic symptoms within 4 weeks of first change in behavior/function
  • Confusion or perplexity
  • Good premorbid functioning (social/occupational)
  • Absence of blunted or flat affect
  • … without good prognostic features: absence of >2 of above factors
  • … with catatonia
  • Severity … with current severity mild/moderate/severe

C) SCHIZOPHRENIA

DSM

  • (Psychotic Episode) >2 of following…, for significant portion of time (1 month, less if treated)
  • Delusions |
  • Hallucinations | - at least one must be 1, 2 or 3
  • Disorganized speech |
  • Grossly disorganized / catatonic behavior
  • Negative Symptoms
  • Impaired function since onset of disturbance, in >1 domain (work; relationships; self-care)
  • If <18, failure to achieve expected level of interpersonal/academic/occupational functioning
  • Signs of disturbance lasting >6 months, with >1 month of active symptoms
  • Includes prodromal/residual symptoms: only (-) symptoms, or >2 attenuated (+) symptoms
  • Schizoaffective/depressive/bipolar disorders with psychotic features ruled out by…
  • No depressive or manic episodes occurring concurrently with active Sx OR
  • Mood episodes occur during active symptoms, but present for a minority of total duration of sx
  • Not attributable to physiological effects of substance or medical condition
  • If history of autism or communication disorder of childhood, diagnosis of schizophrenia added only if predominant hallucinations or delusions for >1 month (in addition to other required symptoms)

Specifiers (only used after 1-year duration of disorder)

  • “… ________ episode(s), currently ___________, ________ severity”
  • Episode
  • … first episode
  • … multiple episodes:at least 2 episodes
  • … continuous: criteria met for majority of illness
  • … unspecified
  • Remission status (currently in…)
  • … acute
  • … in partial remission: maintained improvement (criteria partially filled), after an episode
  • … in full remission no disorder-specific sx, after an episode
  • Severity (if current episode)
  • … with mild/moderate/severe severity
  • Type
  • … with catatonia

D) SCHIZOAFFECTIVE DISORDER

DSM

  • Period of Sx during which there is a mood episode CONCURRENT with criteria A of schizophrenia
  • Delusions or hallucinations for >2 weeks in absence of major mood episode
  • Symptoms of major mood episode are present for MAJORITY of total duration of illness (active/residual)
  • Not attributable to effects of substance or AMC

Specifiers

  • “… ________ episode(s), currently in ___________, ________ severity”
  • Types
  • … bipolar type if manic episode part of presentation
  • … depressive type if ONLY depressive episode part of presentation
  • … with catatonia
  • Episode
  • … first episode
  • … multiple episodes: at least 2 episodes met for majority of illness met for majority of illness
  • … unspecified
  • Remission status (currently in…)
  • … acute episode
  • … partial remission: maintained improvement (criteria partially filled), after an episode
  • … full no disorder-specific symptoms, after an episode disorder-specific
  • symptoms, after an episode
  • Severity
  • … with current severity mild/moderate/severe

E) DELUSIONAL DISORDER

DSM

  • Presence of >1 delusion for >1 month
  • Criterion A (psychotic episode) for schizophrenia never met
  • Functioning not markedly impaired, behavior not bizarre or odd
  • Any mood episodes have been brief relative to duration of delusional period
  • Disturbance not attributable to effects of substance or AMC, not better explained by another mental D/O

Specifiers

  • “… _______ type, ________ episode(s), currently in ___________, ________ severity”
  • Types
  • Erotomanic: another person is in love with patient
  • Grandiose: has some great talent or insight, or made some important discovery
  • Jealous: his/her spouse/lover is unfaithful
  • Persecutory he/she is being conspired against, followed, poisoned, harassed
  • Somatic abnormal bodily functions or sensations
  • Mixed no predominate theme
  • Unspecified theme not clearly determined or specified
  • Bizarre content delusions clearly implausible or not understandable
  • Episode First episode / Multiple episodes
  • Remission Acute episode / Partial remission / Full remission / Continuous / Unspecified
  • Severity Mild/moderate/severe

F) CATATONIA

  • 80-90% happen in mood disorder

Definition: marked ↓ in reactivity to environment.

  • Historically associated with schizophrenia, but may occur with other mental disorders

Catatonic Disorders

  • Catatonia Specifier (associated with another mental disorder)
  • Catatonic Disorder due to AMC
  • Unspecified Catatonia

DSM

  • At least 3 of…
  • Stupor ( no motor response)
  • Mutism ( no verbal response)
  • Catalepsy (passive induction of a posture held against gravity)
  • Posturing (spontaneous and active maintenance of a posture against gravity)
  • Waxy flexibility ( slight, even resistance to positioning by examiner)
  • Negativism (opposition or no response to instructions)
  • Mannerism ( odd, circumstantial caricature of normal actions)
  • Stereotypy ( repetitive, abnormally frequent, non-goal directed movements)
  • Echolalia ( mimicking other’s speech)
  • Echopraxia (mimicking other’s movements)
  • Grimacing
  • Agitation, not influenced by external stimuli

Subtypes

  • Retarded Catatonia – mutism, inhibited movement, posturing, rigidity, negativism, staring
  • Malignant catatonia – fever, autonomic instability (↑BP/RR/HR, diaphoresis), delirium, rigidity
  • Excited catatonia – excessive/purposeless motor activity, restless, stereotypy, agitation, impulsivity, combative
  • +/- delirium

DDX

  • Mood disorder (80-90%)
  • Bipolar D/O, Depressive D/O
  • Neurodevelopmental
  • Psychotic Disorder
  • Catatonia due to AMC
  • CNS lesions, Parkinson’s, NMS, akinetic mutism, status epilepticus
  • Serotonin syndrome, delirium, ETOH w/d, metabolic disturbance
  • Infectious, autoimmune
  • Traumatic
  • Unspecified Catatonia

Treatment

  • Benzos
  • ECT

G) SUBSTANCE / MEDICATION-INDUCED PSYCHOTIC DISORDER

DSM

  • At least one of…
  • Delusions
  • Hallucinations
  • Evidence (from history, physical, lab) of both…
  • Symptoms in Criterion A developed during or soon after substance intoxication/withdrawal/med exposure
  • Involved substance/medication can produce symptoms in Criterion A
  • Disturbance not better explained by a psychotic disorder (not substance/med related), such as…
  • Symptoms preceded onset of substance/med use
  • Symptoms persist for substantial period (>1mo) after cessation of intoxication/withdrawal
  • Other evidence of psychotic disorder (not substance/med related), such as a history
  • Disturbance not occurring exclusively during course of a delirium
  • Disturbance causes clinically significant distress or impairment (social/occupational)

Specifiers

  • Types
  • … with onset during intoxication
  • … with onset during withdrawal
  • Severity
  • …with current severity…Mild / moderate / severe

Associated substances / medications

Substance inducedPrimary
Higher scores on (+) PANSS Sx
Higher scores on (-) PANSS Sx
Higher general psychopathology Sx
Less likely to be aware of psychotic symptoms
Less likely to interpret Sx as manifestation of mental disorder or substance abuse
Visual hallucinations more common
Higher rate of suicidal ideation in the previous year
ASPD more common
Substance use disorders more common
Parental substance use more common

source

H) PSYCHOTIC DISORDER DUE TO ANOTHER MEDICAL CONDITION

DSM

  • Prominent hallucinations OR delusions
  • Evidence (from history/physical/lab) that disturbance is consequence of AMC
  • Disturbance not better explained by another mental disorder
  • Disturbance does not occur exclusively during course of delirium
  • Disturbance causes significant distress or impairment (social/occupational)

Specifiers

  • Type
  • … with delusions
  • … with hallucinations
  • Severity
  • …current severity… mild / moderate / severe

For more information, see “Psychotic Disorder due to AMC”