Psychotic disorders

Key Features of Psychotic Disorders


  • Fixed beliefs that don't change despite conflicting evidence (not related to religious beliefs)

  • Bizarre delusions are completely outlandish while nonbizarre delusions are like the police are tapping my phone

    • Persecutory delusions (MC) - harmed by individual, organization

    • Referential delusions - gestures, comments, environmental cues, directed at them (TV is talking about me)

    • Grandiose delusions - exceptional abilities, wealth, fame

    • Erotomanic delusions - someone is in love with them

    • Nihilistic delusions - major catastrophe will occur

    • Somatic delusions - health/organ function


  • Perception-like experiences NOT from an external stimulus

  • Auditory, visual, somatic (tactile), olfactory (smell), gustatory (taste)

    • Auditory hallucinations (MC): voices, familiar or unfamiliar, distinct from pt's own thoughts

  • Hypnagogic: hallucinations while falling asleep are considered normal

Disorganized thinking

  • Typically inferred from pt's speech

    • Alogia/poverty of content – speech conveys very little information

    • Thought blocking – lost train of thought ➔ abrupt speech interruption

    • Loosening of association – sequence of speech not closely related (one topic to another)

    • Tangentiality – diverge from topic (circumstantiality if eventually returns to original topic)

    • Clanging - rhyming or phonetic similarity

    • Word salad – words are linked incoherently ➔ nonsensical content

    • Perseveration – repeating words/ideas persistently (comes back to same topic after moving on)

Abnormal motor behavior

  • Ranges from childlike "silliness" to unpredictable agitation

  • Stereotyped (repetitive) movements

  • Staring/grimacing

  • Catatonic behavior (↓ reactivity to environment)

    • Rigid - inappropriate or bizarre posture (resists applied force)

    • Negativism - resistance to instructions or lack of verbal/motor responses (mutism/stupor)

    • Catatonic excitement - purposeless/excessive motor activity

    • Echolalia (mimicking speech)

Negative SX

  • Flat affect (no emotional expression)

  • Apathy

  • Anhedonia (no pleasure from activities or new stimuli)

  • Alogia (one word answers)

  • Avolition (↓ purposeful activities)

  • Social withdrawal

Medical "organic" causes of psychosis

  • Delirium (a group of sx, not a disease)

    • Acute confusion (developing over hours to days)

      • Fluctuating levels of alertness/awareness, cognition, attention

      • Usually from infections (sepsis/UTI in elderly) or medications (post-op in elderly)

  • Dementia

  • Cushing syndrome (excess exogenous glucocorticoids, Cushing's dz or ectopic ACTH)

  • Substance use disorder (hallucinogens)

  • Thyroid disorder (thyrotoxicosis)

  • Vitamin B12 (cobalamin) deficiency ➔ anemia, peripheral/optic neuropathy, glossitis, neuropsych sx

  • Systemic lupus erythematosus related neuroinflammatory process ➔ "lupus psychosis"

  • Neuro (neoplasm/epilepsy)

  • Wilson disease - Cu accumulation ➔ extrapyramidal motor ssx

  • Porphyria - impaired synthesis of heme in liver/bone marrow ➔ ABD pain, psychosis, and purple pee

Initial labs

  • Fingerstick CBG (hypoglycemia)

  • Chemistry (electrolyte disturbances)

  • CBC with diff (infection/neoplasm)


  • EtOH

  • Vitamin B12

  • TSH (thyrotoxicosis)

  • Lipid panel (baseline before meds)

  • LFTs (baseline before meds)

  • EKG (baseline QTc before meds)

  • Serum treponema

  • New psychosis typically gets neuroimaging

Brief psychotic disorder

  • At least 1 day and remits by 1 month

  • At least one:

    • Delusions

    • Hallucinations

    • Disorganized speech

      • ± Disorganized/catatonic behavior

  • Specifiers:

    • With marked stressor (MCC) like death of loved one

    • Without marked stressor

    • With catatonia

  • TX with 2nd gen antipsychotics (risperidone)

    • TX agitation that needs sedation with olanzapine (zyprexa) or haloperidol


  • Genetic component (↑ risk if both parents have schizophrenia) typically triggered by psychosocial factor (going away to college)

  • ♂> ♀

  • MRI shows gray matter loss, cortical atrophy, enlarged ventricles

  • Presents in early adulthood (♂ early 20's; ♀ late 20's)

    • Decline in functioning

    • Disturbance present for at least 6 months (active phase or negative sx)

      • At least two (one must be *active phase sx and present for most of one month period):

      • Delusions*

      • Hallucinations*

      • Disorganized speech*

      • Disorganized/catatonic behavior

      • Negative sx

    • NO major depressive or manic episodes during active phase

      • Delusions or hallucinations occurring exclusively during major depressive episode ➔ bipolar disorder with psychotic features

    • Any mood episodes are for a minority of the active and residual phase

      • Mood sx present for a majority of the active phase ➔ schizoaffective disorder (as long as major depressive or manic episode occurs during active-phase)

Schizophreniform disorder

"Pre-schizophrenia" A pt presents with mom who reports 3mo of delusions and disorganized thinking

It isn't brief psychotic disorder because sx have been longer than 1mo... maybe there is chance it will remit (unlikely)

  • SSX and DX equivalent to schizophrenia

    • BUT disturbance present LESS THAN 6 months

  • At least 1 month of sx (unless hospitalized/tx'd)

  • Decline in functioning NOT required

Schizoaffective disorder

A pt presents with manic episode or major depressive episode and you admit them and tx with mood stabilizers...

The mood episode simmers after a few days and during follow up sessions they reveal the thought disorder

  • Major mood episode (major depressive or manic) present for a majority of the total duration

    • WITH

  • Schizophrenia (delusions, hallucinations, disorganization)

    • AND

  • Delusions or hallucinations are present for at least 2 weeks in the absence of a major mood episode

    • To distinguish from bipolar disorder with psychotic features (which generally wont have delusions/hallucinations unless in mood/manic episode)

  • Specifiers

    • Bipolar type: manic episode is part of presentation ± major depressive episodes

    • Depressive type: if only major depressive episodes (no mania)

Delusional disorder

  • At least 1 month of delusions but no other psychotic sx

    • If hallucinations present, they must NOT BE PROMINENT and MUST be related to delusion

      • Delusion of being infested ➔ sensation of being infested

  • Functioning not markedly impaired/behavior not obviously bizarre

    • ± manic or major depressive episode (brief relative to duration of the delusions)

  • Specifiers

    • Erotomanlc type: delusion that another person is in love with the individual.

    • Grandiose type: delusion of having some great (but unrecognized) talent/insight

    • Jealous type: delusion that spouse/lover is unfaithful

    • Persecutory type: delusion involves belief that he or she is being conspired against (followed/poisoned/drugged)

    • Somatic type: delusion involves bodily functions or sensations

  • Delusions/hallucinations for at least 1 day but < 1 month brief psychotic disorder

  • Delusions/hallucinations present < 6 months and still functional schizophreniform disorder

  • Delusions/hallucinations occurring exclusively during a major depressive or manic episode depressive or bipolar disorder w/ psychotic features

  • Mood episode WITH delusions/hallucinations AND preceded/followed by 2wks delusions/hallucinations without mood sxschizoaffective

  • Delusional WITHOUT hallucinations, disorganization, or negative sx for at least one month ➔ delusional disorder