Psychotic Disorders – What are they?

Psychotic disorders are a group of mental health conditions in which symptoms of psychosis occur, such as hallucinations and delusions. Treatment for psychotic disorders often includes medication and therapy.

Types of psychotic disorder

There are various types of psychotic disorders, which involve symptoms of varying severity and length of time, although many psychotic disorders share symptomatic similarities. These symptoms and diagnostic criteria are outlined in The Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5), within the chapter titled Schizophrenia Spectrum and Other Psychotic Disorders ^[1].

Schizophrenia

Schizophrenia is a serious and potentially chronic condition that can require lifelong treatment. Often, a person with schizophrenia lacks insight, meaning that they are not aware of their illness, which can cause difficulties in treating and managing the condition ^[2].

Symptoms of schizophrenia last for at least 6 months and typically include ^[1][2]:

• Hallucinations: The most common types of hallucinations involve seeing or hearing things that are not there, but they can involve any of the five senses.
• Delusions: Delusions are strongly held beliefs that are not based on reality or shared by others, which may include grandiose delusions such as having special powers or abilities, or paranoid delusions such as believing a person or group is trying to cause harm.
• Disorganized thoughts and speech: This can include racing thoughts, jumping from one idea to the next, speaking in jumbled sentences, repeating words or phrases, and the inability to concentrate or remember things.
• Disorganized and unusual behavior: This might include catatonia, eccentric or bizarre behavior, talking or responding to unseen stimuli, and unusual or extreme emotional responses such as laughing at inappropriate times.
• Negative symptoms: This can include social withdrawal, becoming very quiet and not speaking much, not engaging in activities or events, and showing little or no emotion.

Schizoaffective disorder

Schizoaffective disorder also includes the prevalence of psychotic symptoms, particularly hallucinations or delusions, but also involves symptoms of a mood disorder, such as an episode of mania, depression, or both. For this diagnosis, there must be at least two weeks of psychotic symptoms without the presence of mania or depression ^[1][3].

Symptoms of a manic episode can include ^[3]:

• Feeling euphoric or elevated in mood
• Increased activity
• Reduced need for sleep
• Grandiosity, such as feeling an exaggerated sense of confidence, power, or importance

Symptoms of a depressive episode can include:

• Feeling very low in mood
• Sleeping much more than usual, or experiencing sleep disturbances
• Loss in interest in activities and hobbies
• Feeling helpless, guilty, or worthless

Schizophreniform disorder

Someone with schizophreniform disorder will experience the same symptoms as those present in schizophrenia, such as hallucinations, delusions, and disorganized thinking and speech. However, unlike schizophrenia, these symptoms are only present for between one and six months ^[1][4].

A diagnosis of schizophreniform disorder may require altering to a diagnosis of schizophrenia if the symptoms persist beyond 6 months ^[4].

Brief psychotic disorder

Symptoms of brief psychotic disorder include at least one symptom of psychosis, such as hallucinations or delusions, that last between one day and one month, with a return to the individual’s usual level of functioning and mental state following this episode ^[1][5].

Delusional disorder

Symptoms of delusional disorder include at least one month of persistent delusions, without the presence of other symptoms of psychosis and very little change in behaviors or level of functioning ^[1][6].

Hallucinations are not common but may occur within the theme of the experienced delusion. Similarly, changes in mood might occur within the context of the experienced delusion, such as agitation or anxiety alongside a persecutory delusion ^[6].

Medicine or substance-induced psychotic disorder

Symptoms of medicine or substance-induced psychotic disorder can include any signs of psychosis, such as hallucinations, delusions, and disorganized thoughts and speech, along with a lack of insight, so symptoms may appear to present as schizophrenia. However, the symptoms occur during or shortly after intoxication or withdrawal from a medication or illicit substance ^[1][7].

Schizotypal personality disorder

Schizotypal personality disorder differs significantly from other psychotic disorders and from other personality disorders, with symptoms that belong to both groups of disorders, thus often making it a challenge to identify ^[8].

Symptoms may include ^[1][9]:

• Eccentric and unusual behaviors
• Magical thinking, such as believing in superhuman powers or assigning and engaging in spiritual meanings and rituals
• Often seeming paranoid or suspicious of others
• Disorganized thoughts and speech
• Poor social engagement
• Lack of interpersonal relationships
• Social anxiety

Catatonia

Catatonia was previously considered a symptom of schizophrenia but has since been reclassified as a mental health disorder on its own, as it can occur with or without the presence of schizophrenia or within the context of other conditions ^[10].

Symptoms of catatonia can include ^[1][10]:

• Inability to move
• Inability to speak
• Rigid and stiff movements
• Freezing in an unusual position, known as posturing
• Making unusual facial expressions, known as grimacing
• Repeated mimicking of others’ speech or actions, known as echolalia and echopraxia
• Being unresponsive to stimuli or instruction
• Psychomotor agitation, including excessive activity and unpredictable or unrelenting movements

What causes psychotic disorders?

The cause of psychotic disorders is not known, and there are likely several contributing causes and risk factors, which may differ from person to person ^[11][12][13].

Genetics

Research shows that there is a greater risk of developing a psychotic disorder if a direct relative has a psychotic disorder, suggesting a heritability ^[11][12].

However, a large proportion of people with schizophrenia or another psychotic disorder do not have a relative with a similar condition, indicating the prevalence of other contributing risk factors ^[14].

Biology

Studies have shown that people with a psychotic disorder often have a reduced volume of gray matter in their brain, along with higher levels of dopamine activity, thus suggesting a neurological impact in the development of these conditions ^[11].

Some psychotic disorders may also involve abnormalities or changes in levels of other neurotransmitters and areas of the brain ^[3][8].

Environment

Several environmental factors are believed to increase the risk of developing a psychotic disorder, including living in an urban area, being of a low socio-economic status, being an ethnic minority, or being an immigrant ^[11][12].

Pregnancy and birth

Various studies indicate that several factors relating to pregnancy and childbirth can increase the risk of a psychotic disorder, including prenatal malnutrition and drug exposure, premature birth, being born by caesarian section, and being born in winter ^[2][11][12].

Exposure to substances

The risk of developing a psychotic disorder is shown to be greatly increased by early and excessive use of illicit substances, especially cannabis, and alcohol ^[2][7][14].

Childhood experiences

Exposure to bullying, abuse, or other traumatic events in childhood is believed to increase the risk of psychotic disorders developing later in life ^[8][12][13].

How are psychotic disorders diagnosed?

To make a diagnosis of a psychotic disorder, a doctor will first gather a full mental and physical health history of the individual and their family, ascertaining information about any prior diagnoses in the family.

They will likely conduct a thorough physical health examination to determine if there is a presence of any medical conditions or impaired brain functioning that could cause symptoms of a psychotic disorder, which may include an MRI or CT scan ^[5][15].

They will conduct a mental state examination, to gather information about the individual’s thoughts, behaviors, emotions, speech, and sleep, and enquire about the symptoms that the individual has been experiencing. They will ask how and to what extent these symptoms have impacted daily, social, or professional functioning ^[2].

With the information gathered from these examinations and questions, they will utilize diagnostic criteria from the DSM-5 to determine a diagnosis. As psychotic disorders often share similar symptoms, it is vital for the doctor to have a thorough understanding of the presenting symptoms, in order to rule out certain conditions and to clearly identify a specific diagnosis ^[1][15].

For example, diagnostic criteria often require specific information relating to ^[1]:

• How long the symptoms have persisted
• Whether an episode of mania, depression, or other mood changes are present
• The presence of another medical condition
• The use of medications or illicit substances

How are psychotic disorders treated?

As psychotic disorders may involve varying symptoms and impairments in functioning, treatment options for each condition may also vary. However, for all psychotic disorders, the most effective approach to treatment involves the use of both medication and therapeutic intervention ^[15].

Medication

The first line of treatment for a psychotic disorder is the use of an antipsychotic medication. This may include medications such as risperidone, quetiapine, olanzapine, or aripiprazole ^[2][16].

Certain psychotic disorders may benefit from the use of other types of medications, which are often prescribed alongside an antipsychotic. This might include antidepressant medications, mood stabilizers, benzodiazepines, or stimulants ^[3][8].

People often respond differently to medications, so what is effective for one person may not be effective for another, and it may be required to try several medications, or a combination of medications, before finding the most effective treatment.

It is important to take medications exactly as prescribed, as missing doses, taking too much medication in one go, or suddenly stopping a medication can cause serious adverse effects and can worsen symptoms.

Therapy

Various types of therapy are useful in the treatment of psychotic disorders, such as ^{[2][9][15][16]}:

• CBT: Cognitive behavioral therapy can help to provide skills to manage emotional distress and alter negative thoughts and behaviors.
• Family therapy: It can be useful for family members to engage in therapy together, as it provides an opportunity to gain a better understanding of the condition, while learning how best to help their loved one manage their symptoms.
• Psychosocial education: For people whose condition has greatly affected their functioning, it can be useful to spend time with a professional, such as a social worker, to learn or regain skills relating to social and professional functioning and independent living.

Hospitalization

In some cases, it may be necessary for care to be provided in an inpatient setting, if there is a serious risk of harm to the individual or others. The purpose of this is to help stabilize and manage symptoms of the disorder with appropriate professional intervention, aiming to return the individual to the community as soon as it is safe to do so ^[15].