You are in: eMedicine Specialties > Psychiatry > Adult Schizophreniform DisorderArticle Last Updated: Aug 20, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Ravinder N Bhalla, MD, Assistant Clinical Professor of Child Psychiatry, University of Medicine and Dentistry of New Jersey; Medical Director, Mental Health Clinic of Passaic; Consulting Staff, Christian Health Care Center Ravinder N Bhalla is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry Editors: Ronald C Albucher, MD, Chief Medical Officer, Westside Community Services; Consulting Staff, California Pacific Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii; Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin; Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA Author and Editor Disclosure Synonyms and related keywords: schizophreniform disorder, psychosis, schizophrenia, childhood psychosis, delusions, hallucinations, disorganized speech, derailment, incoherence, affective flattening, flat affect, alogia, avolition, psychotherapy DEFINITION AND DIAGNOSTIC FEATURESSection 2 of 10
  Definition Schizophreniform disorder is characterized by the presence of the criterion A symptoms of schizophrenia, including delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms. The disorder, including its prodromal, active, and residual phases, lasts longer than 1 month but less than 6 months. Diagnostic features In order to establish the diagnosis of schizophreniform disorder, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), states that 2 (or more) of the following signs must be present, each for a significant length of time during a 1-month period (or less, if successfully treated).1
Only one criterion A symptom is required if delusions are bizarre, if hallucinations consist of a voice that is keeping up a running commentary on the person's behavior or thoughts, or if 2 or more voices are conversing with each other. Schizoaffective disorder and mood disorder with psychotic features must be excluded, based on determining that (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. The disturbance must not be the result of the direct physiological effects of a substance (eg, drug of abuse, medication) or a general medical condition. An episode of the disorder (including prodromal, active, and residual phases) must last at least 1 month but less than 6 months. If the diagnosis must be made without waiting for recovery, it should be qualified as provisional. Specify if the patient is without good prognostic features, defined as 2 or more of the following:
DIAGNOSIS AND DIFFERENTIAL DIAGNOSISSection 3 of 10
Differential Diagnostic FeaturesDistinguishing schizophreniform disorder from other medical and psychiatric conditions that may present in a floridly psychotic state can be challenging. A detailed history should focus on the following:
Such a detailed history may require the assistance of family members or others familiar with the patient. The often abrupt onset of symptoms, in many cases coupled with the lack of previous episodes, underscores the need for a toxicological and medical evaluation. A full Mental Status Examination helps to establish the diagnosis. Mental status is likely to manifest as a neutral or blunted mood and affect. Evidence of paranoia, ideas of reference, delusions, and hallucinations are usually present. The patient is usually fully oriented with intact memory. A strong possibility of homicidal and even suicidal ideation exists. Attempt to elicit command hallucinations because these could drive a patient to hurt themselves and others. Disorientation and difficulties with recall suggest an organic psychosis rather than a schizophreniform disorder. Laboratory tests, including electrolytes, drug screen, and thyroid studies also help in differential diagnosis. Schizophrenia The symptom profile of a schizophreniform disorder is identical to that of schizophrenia; however, the total duration of illness, including prodromal or residual phases, must be less than 6 months. Also, a deterioration in social or vocational functioning, required as part of criterion B to make the diagnosis of schizophrenia, is not required for schizophreniform disorder. Brief psychotic disorder A diagnosis of brief psychotic disorder requires that symptoms last 1 day to 1 month. Schizophreniform disorder, as with schizophrenia, requires that symptoms be present for at least 1 month. Substance-induced psychotic disorder Although substance-induced psychoses frequently resolve in less than 1 month, sustained substance-induced psychoses in abstinent persons may be indistinguishable from schizophreniform disorder. In the absence of objective diagnostic criteria, the distinction is made based on the extent to which the clinician believes substances have contributed to the current symptom profile. Bipolar disorder and major depression with mood-incongruent features In these disorders, the affective symptoms are clearly more prominent. In mood disorder, the psychotic symptoms are secondary and less intense if present. Sometimes, in the absence of an accurate history, diagnosis must be deferred until longitudinal observation or a more accurate history is available. EPIDEMIOLOGYSection 4 of 10
Incidence, course, prognosis, and other features As with schizophrenia, the prevalence of schizophreniform disorder is equally distributed between the sexes, with peak onset between the ages of 18-24 years in men and ages 24-35 years in women. Unlike schizophrenia, in which prodromal symptoms may develop over several years, schizophreniform disorder requires, among other features, a rather rapid period from the onset of prodromal symptoms to the point at which all criteria for schizophrenia (except duration and deterioration) are met (within 6 mo). According to the American Psychiatric Association, approximately two thirds of patients diagnosed with schizophreniform disorder progress to a diagnosis of schizophrenia. According to Benazzi et al, patients with a good prognosis tend to be retrospectively associated with the affective spectrum of diagnoses rather than the schizophrenic.2 Patients with schizophreniform disorder and patients with schizophrenia share many anatomic and functional cortical deficits in neuropsychological, MRI, single-photon emission computed tomography (SPECT), and positron emission tomography (PET) studies. Studies have not yet elicited a consensus about whether ventricular enlargement is predictive of poor outcome in patients with a schizophreniform disorder. According to Troisi et al, in some patients with a schizophreniform disorder, the presence of negative symptoms and poor eye contact appear to be prognostic of a poor outcome.3 CASE EXAMPLESection 5 of 10
The patient is a 15-year-old girl. Two months ago, she started accusing her mother of taking her things. Gradually, she started keeping to herself more and more. She began smiling to herself and mumbling. She continued to attend school and, until recently, her teacher did not notice the patient's problems. The patient subsequently became unable to respond to the teacher's instructions because she was completely preoccupied by internal stimuli. The school referred the patient to me. She sat calmly and made little eye contact. When I looked at her, she looked away, smiled blandly, and mumbled, "I am not going to tell you." When I gently pressed her, she told me that she heard God talking to her and she also heard "God's enemy sometimes." She refused to elaborate, saying it was a secret. Her mood was neutral, and her affect was inappropriate at times. She was alert and fully oriented. She could recall 3 of 3 items in 5 minutes; memory was intact. She was very guarded, and no delusions were elicited. She denied any suicidal or homicidal ideation. She did not exhibit any abnormal movements and tics. She was attentive and followed 3-step commands. Her general fund of knowledge was average, and she appeared to have average intellect. Her insight and judgment were poor. Her sleep had been reduced, and her appetite was fair. She did not have any physical problems and did not exhibit any signs or symptoms of depression or of elations or euphoria. She did not take any drugs or alcohol and did not have evidence of trauma. Electrolytes, thyroid profile, and drug screen findings were unremarkable. TREATMENTSection 6 of 10
In general, treatment aims to protect and stabilize the patient, to minimize the psychosocial consequences, and to resolve the target symptoms with minimal adverse effects. The patient who may be at risk of harming himself or herself or others requires hospitalization. This allows for complete diagnostic evaluation and helps to ensure the safety of the patient and others. A supportive environment with minimal stimulation is most helpful. As improvement progresses, help with coping skills, problem-solving techniques, and psychoeducational approaches may be added for patients and their families. Patients may benefit from a structured intermediate environment, such as a day hospital, during the initial phases of returning to the community. Psychotherapy Virtually all psychotherapeutic treatment modalities used in the treatment of patients with schizophrenia may be helpful in treating patients with schizophreniform disorder. Insight-oriented therapy is not indicated in patients with schizophreniform disorder because they have limited ability to explore, and they may also be in denial. Patients may experience a high degree of distress related to the onset of symptoms. Both supportive and educational approaches may help patients to manage feelings of turmoil or distress. Group psychotherapy may be helpful; however, patients with schizophreniform disorder who are concerned about their prognosis may become frightened in groups in which they are mixed with patients who have chronic schizophrenia. Thus, care must be taken when forming therapy groups. Family and social-vocational therapies The treatment of patients with schizophreniform disorder frequently involves working with family members and significant others. The family therapy strategies used in working with the families of patients with schizophrenia are highly appropriate for patients with schizophreniform disorder and their families. In light of the variable course of schizophreniform disorder, brief treatment strategies with clear goals may initially be helpful, although treatment strategies must be flexible to allow for the transition to longer-term treatments for patients who progress to schizophrenia. Similarly, social-vocational function may be preserved in patients with schizophreniform disorder. However, in patients exhibiting impairments in these areas, rehabilitative strategies similar to those described for patients with schizophrenia are appropriate. Pharmacotherapy The pharmacotherapy for schizophreniform disorder is similar to that for schizophrenia. At this time, atypical antipsychotics, such as risperidone, olanzapine, quetiapine, and ziprasidone, are commonly used. In November 2003, a new atypical antipsychotic drug, aripiprazole (Abilify), was approved by the US Food and Drug Administration. Aripiprazole has a novel mechanism of action because it is a partial agonist at the dopamine receptors, unlike its predecessors. Dosing strategies appear to be similar to recent approaches to treating patients with schizophrenia, which emphasize the use of minimal but effective doses. Sajatovic et al concluded in one study that both risperidone and quetiapine improved HAMD scores, although quetiapine demonstrated greater improvement when compared with risperidone in all patients.4 In 2006, paliperidone (Invega) was FDA approved. It is a major active metabolite of risperidone and the first oral agent allowing once-daily dosing. Ziprasidone (Geodon) and more recently aripiprazole (Abilify) became available in injection form to help control acute psychosis. These injections are less likely to cause acute extrapyramidal side effects. Adequate treatment or prophylaxis of adverse extrapyramidal effects is critical to patient tolerance of neuroleptic treatment and to medication therapy compliance. Neuroleptic-resistant psychosis in patients with schizophreniform disorder may be managed through approaches similar to those used in patients with schizophrenia, including adjustment of the neuroleptic dose, addition of lithium, or addition of anticonvulsant agents and older typical antipsychotics. Antidepressants may be helpful for mood disturbances associated with schizophreniform disorder, but care must be taken to monitor for possible exacerbations of psychotic symptoms. According to Stromgren, electroconvulsive therapy has been helpful in treating brief reactive psychoses but is generally reserved for medication-resistant cases of schizophreniform disorder. Compton suggested barriers to treatment following the first episode of psychosis including inadequate remission of paranoia, impaired insight, and involvement with the criminal justice system between the patient's discharge from the hospital and the patient's first outpatient appointment. Strong family support appeared to be an important facilitator of treatment engagement during the first several months of outpatient treatment. Various other potential barriers to treatment, such as involuntary status at the time of hospital discharge, are also considered. Patient and family education Efforts should be made to educate both the patients and their families about the early signs of relapse and the need for continuing treatment. Those approaches advance the overall aim of helping patients regain productive roles in society while reducing the risk of relapse. Families with a high degree of emotional expression are likely to cause additional stress to the patient and to increase the likelihood of relapse. (See Interesting Links for a list of organizations that can help to educate patients and their families about schizophreniform disorder.) The patient's condition, the patient's family, and the patient's system of care are a few of the many factors that likely affect treatment engagement early in the course of schizophreniform disorder and schizophrenia. Clinicians should give special attention to these factors when caring for patients who experience their first episode. INTERESTING RESEARCH SUMMARIESSection 7 of 10
Summary I As discussed by Emsley, an international, multicenter, double-blind study was conducted on 183 patients who had a first psychotic episode (ie, provisional schizophreniform disorder or schizophrenia) and who were treated with flexible doses of risperidone or haloperidol for 6 weeks.7 At the end of the study, 63% of patients treated with risperidone and 56% of those treated with haloperidol were clinically improved (350% reduction in Positive and Negative Syndrome Scale [PANSS] total scores). Risperidone was tolerated better than haloperidol. The author stated that "a post-hoc analysis revealed that low doses of these antipsychotics were efficacious in some patients." Other findings from this research also suggest that "patients with a first psychotic episode may require low doses of antipsychotic medications. Studies specifically designed to compare low and high doses of antipsychotics are warranted to help optimize treatment for these patients." Summary II Sanger et al discussed whether the morbidity and mortality associated with schizophrenia could be prevented by providing effective treatment during the first episode of psychosis.8 The authors examined patients with first-episode psychosis to determine the efficacy and safety of olanzapine and haloperidol treatment. In their clinical trial, a subpopulation of first-episode patients was selected from a pool of patients who were diagnosed with schizophrenia, schizoaffective disorder, or schizophreniform disorder. The duration of the patients' current psychotic episodes had to be 5 years or less, and the patients had to be aged 45 years or younger at the onset of their first psychotic symptoms. The results indicated that "in patients who experience first-episode psychosis, olanzapine had a risk-benefit profile significantly superior to that of haloperidol." Results from this study suggest that novel antipsychotic agents (eg, olanzapine) should be considered a preferred option in managing first-episode psychosis because of "safety and efficacy advantages." Summary III A trial described by Sautter et al compared the course of illness of 36 patients who received a diagnosis of schizophreniform disorder or schizophrenia.9 Approximately 3.5 and 4 years after their initial index hospitalization, 2 groups of patients were compared for "differences in positive and negative symptoms of psychosis, interpersonal and occupational role functioning, and other aspects of the deficit state." The patients with schizophreniform disorder showed a low level of negative symptoms at both follow-up examinations. The patients with schizophrenia "initially showed a higher level of negative symptoms, but these symptoms decreased significantly over time." Data from this trial indicate that the course of schizophreniform disorder is "distinct from the course of schizophrenia." Summary IV A study performed by Mathes et al, from the Melbourne Neuropsychiatry Centre, found that patients with schizophreniform disorder and schizophrenia demonstrated a decreased ability to form an internal representation of complex objects.10 Such neuropsychological tests help clinicians to further understand the psychopathology of the disorder. Mathes' study of delay-dependent memory investigated 55 patients with schizophreniform psychosis, 50 patients with established schizophrenia, and a control group of 56 healthy controls. Using the delayed matching-to-sample task from the Cambridge Neuropsychological Test Automated Battery (CANTAB), performance deficits were found in both patient groups after controlling for age and premorbid intelligence quotient (IQ). Even after controlling for simultaneous matching-to-sample ability (ie, perceptual matching), impaired performance in both patient groups was found as soon as the stimuli were removed. Impaired performance was not due to different types of performance errors in patients versus control individuals. Performance in both patient groups was comparable, except for a slight decrease in overall task performance. These findings suggest that the deficit is relatively stable during the course of the illness. PATIENT AND FAMILY EDUCATIONSection 8 of 10
The following links provide valuable information for patients and their families.
CONCLUSIONSection 9 of 10
Schizophreniform disorder is a serious mental disorder with symptoms similar to those of schizophrenia. Early diagnosis of this disorder is crucial, as is early intervention with medication, supportive therapy, and patient and family education. REFERENCESSection 10 of 10
Schizophreniform Disorder excerpt Article Last Updated: Aug 20, 2007 |
