Schizophreniform disorder

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Definition

Schizophreniform disorder (SFD) is a time-limited illness wherein the sufferer has experienced at least two of the major symptoms of psychosis for longer than one month but fewer than six months. Hallucinations , delusions , and strange bodily movements or lack of movements (catatonic behavior) are all symptoms that may be observed. Additionally, minimal or peculiar speech, lack of drive to act on one's own behalf, bizarre behavior, a wooden quality to one's emotions or near-absent emotionality are all typical psychotic symptoms that may occur in SFD.

Part of defining SFD involves examining possible biological influences on the development of the individual's psychotic symptoms. When the psychotic features result from a physical disease, a reaction to medication, or intoxication with drugs or alcohol, then these symptoms are not considered SFD. Also, if hallucinations, delusions or other psychotic symptoms are experienced solely during episodes of clinical depression or mania, then SFD is not diagnosed. Instead, a mood disorder diagnosis is given.

The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision, or DSM-IV-TR , produced by the American Psychiatric Association in 2000, outlines the diagnostic criteria for SFD.

Description

The person experiencing SFD shows at least two psychotic symptoms, which may be either "positive" or "negative" psychotic symptoms. The terms "positive" and "negative" are not used in their usual meanings of positive being good and negative being bad. In discussing psychosis, positive and negative are used with a more formal medical connotation. Medically, "positive" refers to a factor being present that does not normally occur, or to an excess of some factor or behavior. Positive symptoms of psychosis include hallucinations, delusions, strange bodily movements or frozen movement (catatonic behavior), peculiar speech and bizarre or primitive (socially inappropriate) behavior. Negative, when used in medical fashion, refers to an absence or deficiency of a factor that is usually at a reasonable level during normal functioning. Various deficiencies in behavior, emotionality or speech constitute the negative symptoms of psychosis which are observed in some cases of SFD. Negative symptoms of psychosis include avolition , affective flattening and alogia .

Avolition is a lack of effort to act on one's own behalf or to engage in behaviors directed at accomplishing a purpose. Affective flattening or blunted affect refers to a decrease or low level of emotion, shown as a wooden quality to one's emotions or a near absence of emotionality. Alogia derives from the Greek root term for speech or thought, and the "a" that begins the word indicates an absence. Thus, alogia refers to a disruption in thought process reflected in the person's speech. One form of alogia is poverty of speech . Impoverished speech is brief, limited, terse and generally emerges only in response to questions or prompts rather than flowing spontaneously. An impairment termed poverty of content occurs when the information or concepts that the individual is attempting to convey cannot be understood because of limitations in the method of communicating. The meaning behind the phrases is obscured or missing. Typically, in poverty of content, the person's speech, while comprehensible in terms of its orderliness of grammar and vocabulary, does not convey substantial meaning because the phrasing is overly concrete and literal or overly abstract and fanciful.

Among the various positive symptoms of psychosis that can be a part of SFD, delusions are a fairly common psychotic feature. Delusions are strongly held irrational and unrealistic beliefs that are highly resistant to alteration. Even when the person encounters evidence that would invalidate the delusion, the unjustified and improbable belief remains a conviction. Often, delusions are paranoid or persecutory in tone. In these types of delusions, the person is excessively suspicious and continually feels at the mercy of conspirators believed to be determined to cause harm to the sufferer. However, delusions can also take on other overtones. Some delusions are grandiose, or involve elaborate love fantasies (erotomanic delusions). Delusions may involve somatic content, or may revolve around extreme and irrational jealousy.

Peculiar or disorganized speech, catatonic behavior and bizarre or primitive behavior are all additional positive psychotic symptoms that may occur in SFD. Disorganized speech is seen in some cases of SFD. Speech disorganization can involve words blended together into incomprehensible statements, also known as "word salad." In some persons disorganized speech takes the form of echolalia, which is the repetition of another person's exact spoken words, restated either immediately after the initial speaker or after a delay of minutes to hours. Catatonic behavior or catatonia involves the presence of one of the possible extremes related to movement. Catalepsy is the motionless end of the catatonic spectrum; in catalepsy, a person may remain unmoving in one fixed position for long periods. The opposite end of the catatonia phenomenon is demonstrated in rapid or persistently repeated movements, recurrent grimacing and odd facial expressions, and contorted or strange gestures. Bizarre or primitive behavior in SFD ranges from child-like behaviors in unsuitable circumstances to unusual practices such as hoarding refuse items perceived by the sufferer to be valuable, caching food all over the home, or wandering purposelessly through the streets.

Only rarely would all these various psychotic symptoms be observed simultaneously in one person with SFD. Instead, each individual with SFD has a constellation of symptoms, practices and thought processes that is unique to that person. However, frequent occurrence of at least two of these psychotic symptoms persisting for one month to six months is considered to be SFD. A different diagnosis, which includes the presence of psychotic symptoms, is given if the symptoms have been present for longer than six months. Also, if there is some other psychiatric syndrome that better explains the behaviors, or if there are biological causes (such as a physical illness, like a brain tumor) that caused the symptoms to appear, another diagnosis is utilized.

Unlike any other diagnoses offered in DSM-IV-TR , the SFD diagnosis always includes an indication of the patient's prognosis . Prognosis refers to the potential outcome for an individual with a particular illness, based on the features already observed and the usual course of the illness. If an individual with SFD has several positive prognostic factors, then there is a much higher likelihood of complete recovery without relapse into psychosis. Positive prognostic factors in SFD include: prominent confusion during the illness, rapid (rather than gradual) development of symptoms during a four-week period, good previous interpersonal and goal-oriented functioning, and lack of negative symptoms of psychosis.

Causes and symptoms

Causes

Several views regarding the causes of the disorder have been put forth by researchers and clinicians.

AN EARLY PHASE OF ANOTHER PSYCHIATRIC DISORDER. A number of follow-up studies have examined the relationship between SFD and other disorders such as schizophrenia , schizoaffective disorder and bipolar disorder . The majority of these studies have found that between 50% and 75% of persons with SFD eventually develop schizophrenia. Of those persons with a history of SFD who do not subsequently receive a schizophrenia diagnosis, only a small portion have no further psychiatric disturbance. The other diagnoses that may be observed in persons formerly diagnosed with SFD are schizoaffective disorder or bipolar disorder (the Type I form). The most common subsequent diagnosis is schizophrenia, with the next most common being schizoaffective disorder. Because of the high rate of later schizophrenia in SFD sufferers, many clinicians have come to think of SFD as being an initial phase of schizophrenia. It is impossible to identify, during an episode of SFD, whether any one particular case will improve without any relapse into psychotic symptoms, or if the mental health client is actually in the early phase of schizophrenia or schizoaffective disorder. Follow-up studies indicate that being frequently confused during a period of SFD is often associated with gradual complete recovery.

LENGTHY POSTPARTUM PSYCHOSIS. Intense hormonal changes occurring in childbirth and immediately afterward can result in a short-term psychotic disorder often referred to as postpartum psychosis . When the psychotic symptoms in this condition persist for longer than one month but fewer than six months, the SFD diagnosis may be given.

DIATHESIS X STRESS. Diathesis is a medical term meaning that some element of one's physiology makes one particularly prone to develop an illness if exposed to the right conditions. Diathesis is another way of saying there is a personal predisposition to develop a disorder; the predisposition is biologically based and is genetically acquired (inherited in the person's genes). Temporary psychotic reactions may occur in persons who have the diathesis for psychosis, when the individual is placed under marked stress . The stress may result from typical life transition experiences such as moving away from home the first time, being widowed or getting divorced. In some cases, the stressor is more intense or unusual, such as surviving a natural disaster, wartime service, being taken hostage or surviving a terrorist attack. When the psychotic responses last less than a month, then this reaction is labeled " brief psychotic disorder ." Highly susceptible persons may show psychotic symptoms for greater than one month and might be given the SFD diagnosis. If the psychotic symptoms are purely reactive, when the stressor ceases or more support is available, the individual is likely to return to a non-psychotic mode of functioning. In persons with a strong diathesis or predisposition, the initial psychotic reaction may "tip over" from the category of a brief reaction into a longer-term, persistent psychiatric disorder. The diathesis x stress model is applied not only to SFD, but also to schizophrenia, schizoaffective disorder and the most severe forms of mood disorders.

CULTURALLY DEFINED DISORDERS. Many cultures have forms of mental disorder, unique to that culture, that would meet criteria for SFD. In culturally defined disorders, a consistent set of features and presumed causes of the syndrome are localized to that community. Such disorders are termed "culture-bound." Examples of culture-bound syndromes that might meet SFD criteria are amok (Malaysia), or locura (Latino Americans). Amok is a syndrome characterized by brooding, persecutory delusions and aggressive actions. Locura involves incoherence, agitation, social dysfunction, erratic behavior, and hallucinations.

Symptoms

DSM-IV-TR provides three major criteria for SFD:

AT LEAST TWO PERSISTENT POSITIVE OR NEGATIVE SYMPTOMS OF PSYCHOSIS.

delusions
disorganized speech which is strange, peculiar, difficult to comprehend
disorganized (bizarre or child-like) behavior
catatonic behavior
hallucinations
negative symptoms (affective flattening, alogia, avolition)

LIMITED DURATION.

The psychotic symptoms have occurred for at least one month but less than six months.

CAUSE. The symptoms cannot:

occur as part of a mood disorder
occur as part of schizoaffective disorder or schizophrenia
be due to intoxication with drugs or alcohol
be an adverse reaction to a medication
be caused by a physical injury or medical illness

Demographics

The actual rate of SFD is unknown, mainly because SFD is difficult to measure except in retrospect. In the first few weeks of symptoms, SFD cannot be differentiated from brief psychotic disorder. Once the symptoms persist past one month and are identified as SFD, six months or more must pass before one can determine if a mental health consumer had "classic" SFD or was in the early phase of a more chronic mental disorder. Given that a majority of SFD sufferers go on to be diagnosed with schizophrenia, the best inferences about demographics and gender differences in SFD would be drawn from similar information available regarding schizophrenia.

Diagnosis

Despite the clarity of the DSM-IV-TR criteria, identification of SFD is less than clear-cut. The emphasis on the length of time that symptoms have been evident and the presence or absence of good prognostic factors make SFD one of the most unusually defined of the DSM-IV-TR disorders. While duration of symptoms is the major distinction among brief psychotic disorder, SFD and schizophrenia, it can be difficult to clearly determine the length of time symptoms have existed. An additional complication is that the cultural context in which the "psychotic symptoms" are experienced determines whether the behaviors are viewed as pathological or acceptable. When psychotic-like behaviors are expected to occur normally as part of the person's culture or religion, and when the behaviors occur in a culturally positive context such as a religious service, SFD would not be diagnosed.

Information about current and past experiences is collected in an interview with the client, and possibly in discussion with the client's family. Psychological assessment instruments, such as the Rorschach technique , the Minnesota Multiphasic Personality Inventory , and mood disorder questionnaires or structured diagnostic interviews may also be used to aid in the diagnosis.

Treatments

The main line of treatment for SFD is antipsychotic medication. These medications are often very effective in treating SFD. Mood-stabilizing drugs similar to those used in bipolar disorder may be used if there is little response to other interventions. Postpartum psychosis is also treated with antipsychotics and possibly, hormones. Supportive therapy and education about mental illness is often valuable. The most useful interventions in culture-bound syndromes are those that are societally prescribed; for example, a sacred ceremony to ease the restless spirits of deceased ancestors might be a usual method of ending the psychotic-like state, in that particular culture.

Prognosis

Given the large number of mental health consumers with SFD who go on to be diagnosed with a more chronic form of mental illness, the prognosis is fairly poor. As noted earlier, prominent confusion during the illness, rapid (rather than gradual) development of symptoms during a four-week period, good previous interpersonal and goal-oriented functioning and lack of negative symptoms of psychosis suggest a better outcome.

Prevention

If the SFD is a persistent postpartum psychosis, a prevention option is to avoid having additional children. The physician may anticipate the postpartum problem and prescribe an antipsychotic medication regimen to begin immediately after delivery as a preventive measure. Although prevention of psychotic disorders is difficult to accomplish, the earlier treatment begins, the better the outcome. Therefore, efforts are more generally focused on early identification of SFD and other psychotic-spectrum disorders.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.

PERIODICALS

Ferfel D. "Rationale and guidelines for the inpatient treatment of acute psychosis." Journal of Clinical Psychiatry 61, Suppl 14 (2000): 27–32.

Iancu, I, P. V. Dannon, R. Ziv, and E. Lepkifker. "A follow-up study of patients with DSM-IV schizophreniform disorder." Canadian Journal of Psychiatry 47, no. 1 (2000): 56–60.

Kulhara, P., S. Chakrabarti. "Culture, schizophrenia and psychotic disorder." Psychiatric Clinics of North America 24, no. 3 (2001): 449–464.

Stocky A, J. Lynch. "Acute psychiatric disturbance in pregnancy and the puerperium." Baillere's Best Practices and Research in Obstetrics and Gynaecology 14, no. 1(2000): 73–87.

Deborah Rosch Eifert, Ph.D.