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NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES (INI)

PRESENTATION ON
OTHER PSYCHOTIC DISORDERS
BRIEF PSYCHOTIC DISORDERS
SCHIZOAFFECTIVE DISORDER
SUBJECT: MENTAL HEALTH NURSING
UNIT: VIII: SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

SUBMITTED TO

SUBMITTED BY

DR. SAILAXMI GANDHI

NEETHU ROSE JOHN

ASSO. PROFESSOR

IIND YEAR MSc Nsg

NIMHANS

NIMHANS

OTHER PSYCHOTIC DISORDERS


The major nonorganic psychotic disorders are schizophrenia and mood disorders. In addition to
these two, there are other nonorganic psychoses some of which have been sometimes labeled as
the third psychoses or other psychotic disorders.
F21 Schizotypal disorder
A disorder characterized by eccentric behaviour and anomalies of thinking and affect which
resemble those seen in schizophrenia, though no definite and characteristic schizophrenic
anomalies have occurred at any stage. There is no dominant or typical disturbance, but any of the
following may be present:
Clinical picture
(a) Inappropriate or constricted affect (the individual appears cold and aloof);
(b) Behaviour or appearance that is odd, eccentric, or peculiar;
(c) Poor rapport with others and a tendency to social withdrawal;
(d) Odd beliefs or magical thinking, influencing behaviour and inconsistent with subcultural
norms;
(e) Suspiciousness or paranoid ideas;
(f) Obsessive ruminations without inner resistance, often with dysmorphophobic, sexual or
aggressive contents;
(g) Unusual perceptual experiences including somatosensory (bodily) or other illusions,
depersonalization or derealization;
(h) Vague, circumstantial, metaphorical, over elaborate, or stereotyped thinking, manifested by
odd speech or in other ways, without gross incoherence;
(i) Occasional transient quasi-psychotic episodes with intense illusions, auditory or other
hallucinations, and delusion-like ideas, usually occurring without external provocation.
The disorder runs a chronic course with fluctuations of intensity. Occasionally it evolves into
overt schizophrenia. There is no definite onset and its evolution and course are usually those of a
personality disorder. It is more common in individuals related to schizophrenics and is believed
to be part of the genetic "spectrum" of schizophrenia.
Diagnostic guidelines
This diagnostic rubric is not recommended for general use because it is not clearly demarcated
either from simple schizophrenia or from schizoid or paranoid personality disorders. If the term
is used, three or four of the typical features listed above should have been present, continuously
or episodically, for at least 2 years. The individual must never have met criteria for schizophrenia
itself. A history of schizophrenia in a first-degree relative gives additional weight to the diagnosis
but is not a prerequisite.

F22 Persistent delusional disorders


This group includes a variety of disorders in which long-standing delusions constitute the only,
or the most conspicuous, clinical characteristic and which cannot be classified as organic,
schizophrenic, or affective. They are probably heterogeneous, and have uncertain relationships to
schizophrenia. The relative importance of genetic factors, personality characteristics, and life
circumstances in their genesis is uncertain and probably variable.
F22.0 Delusional disorder
Clinical picture
This group of disorders is characterized by the development either of a single delusion or of a set
of related delusions which are usually persistent and sometimes lifelong. The delusions are
highly variable in content. Often they are persecutory, hypochondriacal, or grandiose, but they
may be concerned with litigation or jealousy, or express a conviction that the individual's body is
misshapen, or that others think that he or she smells or is homosexual. Other psychopathology is
characteristically absent, but depressive symptoms may be present intermittently, and olfactory
and tactile hallucinations may develop in some cases. Clear and persistent auditory
hallucinations (voices), schizophrenic symptoms such as delusions of control and marked
blunting of affect, and definite evidence of brain disease are all incompatible with this diagnosis.
However, occasional or transitory auditory hallucinations, particularly in elderly patients, do not
rule out this diagnosis, provided that they are not typically schizophrenic and form only a small
part of the overall clinical picture. Onset is commonly in middle age but sometimes, particularly
in the case of beliefs about having a misshapen body, in early adult life. The content of the
delusion, and the timing of its emergence, can often be related to the individual's life situation,
e.g. persecutory delusions in members of minorities. Apart from actions and attitudes directly
related to the delusion or delusional system, affect, speech, and behaviour are normal.
Subtypes
1. Erotomanic Type. Delusions that another person of higher status is in love with him or her.
2. Grandiose Type. Delusions of inflated worth, power, knowledge, special identity, or special
relationship to a deity or famous person.
3. Jealous Type. Delusions that ones sexual partner is unfaithful.
4. Persecutory Type. Delusions that one is being malevolently treated in some way.
5. Somatic Type. Delusions that the person has some physical defect, disorder, or disease.
6. Mixed Type. When the disorder is mixed, delusions are prominent, but no single theme is
predominant.
When the content of delusions is predominantly jealousy (infidelity) involving the spouse, it is
called as Othello syndrome or conjugal paranoia. A syndrome of late paraphrenia has also been
described in the elderly. Although it was earlier considered a subtype of delusional disorders, it is
presently diagnosed under paranoid schizophrenia. When the content of delusions is predominantly characterized by presence of hypochondriacal delusions, it is called as monosymptomatic
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hypochondriacal psychosis (MHP), delusional parasitosis, or hypochondriacal paranoia. The


common delusions include infestations by worms or foreign bodies, emitting a foul odour
(delusional halitosis), body (or its parts) being ugly or misshapen (delusional dysmorphophobia).
When content of delusions is erotic (eroto manic) the condition is known as Clerambaults
syndrome or erotomania. Occurring most often in women, there is an erotic conviction that a
person with (usually a) higher status is in love with the patient. When the content of delusions is
predominantly grandiose, then the patient usually has delusions with religious or political content
and may believe self to be a leader with higher aims of spreading peace, making war or
spreading a message in the world.
Diagnostic guidelines
Delusions constitute the most conspicuous or the only clinical characteristic. They must be
present for at least 3 months and be clearly personal rather than subcultural. Depressive
symptoms or even a full-blown depressive episode (F32.-) may be present intermittently,
provided that the delusions persist at times when there is no disturbance of mood. There must be
no evidence of brain disease, no or only occasional auditory hallucinations, and no history of
schizophrenic symptoms (delusions of control, thought broadcasting, etc.).
F22.8 Other persistent delusional disorders
This is a residual category for persistent delusional disorders that do not meet the criteria for
delusional disorder (F22.0). Disorders in which delusions are accompanied by persistent
hallucinatory voices or by schizophrenic symptoms that are insufficient to meet criteria for
schizophrenia (F20.-) should be coded here. Delusional disorders that have lasted for less than 3
months should, however, be coded, at least temporarily, under F23.-.
INDUCED DELUSIONAL DISORDER
Clinical picture
A rare delusional disorder shared by two or occasionally more people with close emotional links.
Only one person suffers from a genuine psychotic disorder; the delusions are induced in the other
and usually disappear when the people are separated. The psychotic illness of the dominant
person is most commonly schizophrenic, but this is not necessarily or invariably so. Both the
original delusions in the dominant person and the induced delusions are usually chronic and
either persecutory or grandiose in nature. Delusional beliefs are transmitted this way only in
uncommon circumstances. Almost invariably, the people concerned have an unusually close
relationship and are isolated from others by language, culture or geography. The individual in
whom the delusions are induced is usually dependent on or subservient to the person with the
genuine psychosis.
Diagnostic guidelines
A diagnosis of induced delusional disorder should be made only if:
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(a) Two or more people share the same delusion or delusional system and support one another in
this belief.
(b) They have an unusually close relationship of the kind described above.
(c) There is temporal or other contextual evidence that the delusion was induced in the passive
member(s) of the pair or group by contact with the active member.
Induced hallucinations are unusual but do not negate the diagnosis. However, if there are reasons
for believing that two people living together have independent psychotic disorders neither should
be coded here, even if some of the delusions are shared.

BRIEF PSYCHOTIC DISORDER

F23 ACUTE AND TRANSIENT PSYCHOTIC DISORDERS

The DSM-5 identifies Brief Psychotic Disorder as a recurrent, transient thought disorder, which
typically occurs in adolescence or young adulthood. By definition, it is of short duration,
although it can result in increased risk of suicidality, or inability to perform self care (American
Psychiatric Association, 2013). Brief psychotic disorder is an acute and transient psychotic
syndrome, thus, most individuals diagnosed with brief psychotic disorder under DSM V are
classified as having acute and transient psychotic disorders under the ICD-10

HISTORY

Patients with disorders similar to brief psychotic disorder were previously classified as having
reactive, hysterical, stress, and psychogenic psychoses. Reactive psychosis was often used as a
synonym for good-prognosis schizophrenia. In 1913, Karl Jaspers described several essential
features for the diagnosis of reactive psychosis, including an identifiable and extremely traumatic
stressor, a close temporal relation between the stressor and the development of the psychosis and
a generally benign course for the psychotic episode. Jaspers also stated that the content of the
psychosis often reflected the nature of the traumatic experience and that the development of the
psychosis seemed to serve a purpose for the patient often as an escape from a traumatic
condition.
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EPIDEMIOLOGY

The exact incidence and prevalence of brief psychotic disorder is not known, but it is generally
considered uncommon. The disorder occurs more often among younger patients (20s and 30s)
than among older patients. Reliable data on sex and sociocultural determinants are limited,
although some findings suggest a higher incidence in women and persons in developing
countries. Such epidemiological patterns are sharply distinct from those of schizophrenia. Some
clinicians indicate that the disorder may be seen most frequently in patients from low
socioeconomic classes and in those who have experienced disasters or major cultural changes
(e.g. immigrants). The age of onset in industrialized settings may be higher than in developing
countries. Persons who have gone through major psychosocial stressors may be at greater risk for
subsequent brief psychotic disorder

ETIOLOGY

The cause of brief psychotic disorder is unknown. Patients who have a personality disorder may
have a biological or psychological vulnerability for the development of psychotic symptoms,
particularly those with borderline, schizoid, schizotypal or paranoid qualities. Some patients with
brief psychotic disorder have a history of schizophrenia or mood disorders in their families, but
this finding is nonconclusive. Psychodynamic formulations have emphasized the presence of
inadequate coping mechanisms and the possibility of secondary gain for patients with psychotic
symptoms. Additional psychodynamic theories suggest that the psychotic symptoms are a
defense against a prohibited fantasy, the fulfillment of an unattained wish, or an escape from a
stressful psychosocial situation

CLINICAL FEATURES AND DIAGNOSTIC CRITERIA

According To ICD 10
Clinical features
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Systematic clinical information that would provide definitive guidance on the classification of
acute psychotic disorders is not yet available, and the limited data and clinical tradition that must
therefore be used instead do not give rise to concepts that can be clearly defined and separated
from each other. In the absence of a tried and tested multiaxial system, the method used here to
avoid diagnostic con- fusion is to construct a diagnostic sequence that reflects the - 86 - order of
priority given to selected key features of the disorder. The order of priority used here is:
(a) An acute onset (within 2 weeks) as the defining feature of the whole group;
(b) The presence of typical syndromes;
(c) The presence of associated acute stress.
The classification is nevertheless arranged so that those who do not agree with this order of
priority can still identify acute psychotic disorders with each of these specified features.
It is also recommended that whenever possible a further subdivision of onset be used, if
applicable, for all the disorders of this group. Acute onset is defined as a change from a state
without psychotic features to a clearly abnormal psychotic state, within a period of 2 weeks or
less. There is some evidence that acute onset is associated with a good outcome, and it may be
that the more abrupt the onset, the better the outcome. It is therefore recommended that,
whenever appropriate, abrupt onset (within 48 hours or less) is specified.
The typical syndromes that have been selected are first, the rapidly changing and variable state,
called here "polymorphic", that has been given prominence in acute psychotic states in several
countries, and second, the presence of typical schizophrenic symptoms.
Associated acute stress can also be specified, with a fifth character if desired, in view of its
traditional linkage with acute psychosis. The limited evidence available, however, indicates that
a substantial proportion of acute psychotic disorders arise without associated stress, and
provision has therefore been made for the presence or the absence of stress to be recorded.
Associated acute stress is taken to mean that the first psychotic symptoms occur within about 2
weeks of one or more events that would be regarded as stressful to most people in similar
circumstances, within the culture of the person concerned. Typical events would be bereavement,
unexpected loss of partner or job, marriage, or the psychological trauma of combat, terrorism,
and torture. Long-standing difficulties or problems should not be included as a source of stress in
this context.
Complete recovery usually occurs within 2 to 3 months, often within a few weeks or even days,
and only a small proportion of patients with these disorders develop persistent and disabling
states. Unfortunately, the present state of knowledge does not allow the early prediction of that
small proportion of patients who will not recover rapidly.
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These clinical descriptions and diagnostic guidelines are written on the assumption that they will
be used by clinicians who may need to make a diagnosis when having to assess and treat patients
within a few days or weeks of the onset of the disorder, not knowing how long the disorder will
last. A number of reminders about the time limits and transition from one disorder to another
have therefore been included, so as to alert those recording the diagnosis to the need to keep
them up to date.
Diagnostic guidelines
None of the disorders in the group satisfies the criteria for either manic (F30.-) or depressive
(F32.-) episodes, although emotional changes and individual affective symptoms may be
prominent from time to time.
These disorders are also defined by the absence of organic causation, such as states of
concussion, delirium, or dementia. Perplexity, preoccupation, and inattention to the immediate
conversation are often present, but if they are so marked or persistent as to suggest delirium or
dementia of organic cause, the diagnosis should be delayed until investigation or observation has
clarified this point. Similarly, disorders in F23.- should not be diagnosed in the presence of
obvious intoxication by drugs or alcohol. However, a recent minor increase in the consumption
of, for instance, alcohol or marijuana, with no evidence of severe intoxication or disorientation,
should not rule out the diagnosis of one of these acute psychotic disorders.
It is important to note that the 48-hour and the 2-week criteria are not put forward as the times of
maximum severity and disturbance, but as times by which the psychotic symptoms have become
obvious and disruptive of at least some aspects of daily life and work. The peak disturbance may
be reached later in both instances; the symptoms and disturbance have only to be obvious by the
stated times, in the sense that they will usually have brought the patient into contact with some
form of helping or medical agency. Prodromal periods of anxiety, depression, social withdrawal,
or mildly abnormal behaviour do not qualify for inclusion in these periods of time.
A fifth character may be used to indicate whether or nor the acute psychotic disorder is
associated with acute stress:
F23.x0 Without associated acute stress
F23.x1 With associated acute stress
F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
Clinical features
An acute psychotic disorder in which hallucinations, delusions, and perceptual disturbances are
obvious but markedly variable, changing from day to day or even from hour to hour. Emotional
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turmoil, with intense transient feelings of happiness and ecstasy or anxieties and irritability, is
also frequently present. This polymorphic and unstable, changing clinical picture is
characteristic, and even though individual affective or psychotic symptoms may at times be
present, the criteria for manic episode (F30.-), depressive episode (F32.-), or schizophrenia
(F20.-) are not fulfilled. This disorder is particularly likely to have an abrupt onset (within 48
hours) and a rapid resolution of symptoms; in a large proportion of cases there is no obvious
precipitating stress.
If the symptoms persist for more than 3 months, the diagnosis should be changed. (Persistent
delusional disorder (F22.-) or other nonorganic psychotic disorder (F28) is likely to be the most
appropriate.)
Diagnostic guidelines
For a definite diagnosis:
(a) The onset must be acute (from a nonpsychotic state to a clearly psychotic state within 2
weeks or less);
(b) There must be several types of hallucination or delusion, changing in both type and intensity
from day to day or within the same day;
(c) There should be a similarly varying emotional state; and
(d) In spite of the variety of symptoms, none should be present with sufficient consistency to
fulfill the criteria for schizophrenia (F20.-) or for manic or depressive episode (F30.- or F32.-).
F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia
An acute psychotic disorder which meets the descriptive criteria for acute polymorphic psychotic
disorder (F23.0) but in which typically schizophrenic symptoms are also consistently present.
Diagnostic guidelines
For a definite diagnosis, criteria (a), (b), and (c) specified for acute polymorphic psychotic
disorder (F23.0) must be fulfilled; in addition, symptoms that fulfill the criteria for schizophrenia
(F20.-) must have been present for the majority of the time since the establishment of an
obviously psychotic clinical picture.
If the schizophrenic symptoms persist for more than 1 month, the diagnosis should be changed
to schizophrenia (F20.-).
F23.2 Acute schizophrenia-like psychotic disorder

An acute psychotic disorder in which the psychotic symptoms are comparatively stable and
fulfill the criteria for schizophrenia (F20.-) but have lasted for less than 1 month. Some degree of
emotional variability or instability may be present, but not to the extent described in acute
polymorphic psychotic disorder (F23.0).
Diagnostic guidelines
For a definite diagnosis:
(a) The onset of psychotic symptoms must be acute (2 weeks or less from a nonpsychotic to a
clearly psychotic state);
(b) Symptoms that fulfill the criteria for schizophrenia (F20.-) must have been present for the
majority of the time since the establishment of an obviously psychotic clinical picture;
(c) The criteria for acute polymorphic psychotic disorder are not fulfilled. If the schizophrenic
symptoms last for more than 1 month, the diagnosis should be changed to schizophrenia (F20.-).
F23.3 other acute predominantly delusional psychotic disorders
Acute psychotic disorders in which comparatively stable delusions or hallucinations are the main
clinical features, but do not fulfill the criteria for schizophrenia (F20.-). Delusions of persecution
or reference are common, and hallucinations are usually auditory (voices talking directly to the
patient).
Diagnostic guidelines
For a definite diagnosis:
(a) The onset of psychotic symptoms must be acute (2 weeks or less from a nonpsychotic to a
clearly psychotic state);
(b) Delusions or hallucinations must have been present for the majority of the time since the
establishment of an obviously psychotic state; and
(c) The criteria for neither schizophrenia (F20.-) nor acute polymorphic psychotic disorder
(F23.0) are fulfilled.
If delusions persist for more than 3 months, the diagnosis should be changed to persistent
delusional disorder (F22.-). If only hallucinations persist for more than 3 months, the diagnosis
should be changed to other nonorganic psychotic disorder (F28).
F23.8 Other acute and transient psychotic disorders
Any other acute psychotic disorders that are unclassifiable under any other category in F23 (such
as acute psychotic states in which definite delusions or hallucinations occur but persist for only
small proportions of the time) should be coded here. States of undifferentiated excitement should
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also be coded here if more detailed information about the patient's mental state is not available,
provided that there is no evidence of an organic cause.
F23.9 Acute and transient psychotic disorder, unspecified
Includes: (brief) reactive psychosis NOS
TREATMENT
1. Antipsychotics are the mainstay of treatment, and are used to control agitation and psychotic
features. Usually lower doses of antipsychotics are needed. However, in the initial stages the
patient may not take oral medication. In such cases, parenteral administration of antipsychotics
(with or without benzodiazepines such as lorazepam or diazepam) may be needed. The first use
of parenteral antipsychotics in an antipsychotic-naive patient should be carefully considered, as
there is a higher risk of neuroleptic malignant syndrome (NMS) in these patients. Long-term use
of antipsychotics should be preferably avoided in these patients
2. ECT may be needed in cases with marked agitation and emotional turmoil, as well as in cases
where there is a danger to self and/or others.
3. Antidepressants may be rarely needed as adjuvant in some cases with associated depression.
4. Psychotherapy and other psychological interventions may be needed in cases with associated
stress, as well as for psycho education for the patient and family. Engagement with psychological
treatment is usually after the acute episode is under control and the patient can communicate
his/her fears and anxieties.

F25 SCHIZOAFFECI1VE D1SORDER

As the term implies, schizoaffective disorder has features of both schizophrenia and affective
disorders. In ICD-I0 schizoaffective disorder is a distinct entity and can be applied to patients
who have co-occurring mood symptoms and schizophrenic-like mood-incongruent psychosis.
These are episodic disorders in which both affective and schizophrenic symptoms are prominent
within the same episode of illness, preferably simultaneously, but at least within a few days
between each other. Their relationship to typical mood (affective) disorders (F30-F39) and to
schizophrenic disorders (F20-F24) is uncertain. They are given a separate category because they
are too common to be ignored. Patients who suffer from recurrent schizoaffective episodes,
particularly those whose symptoms are of the manic rather than the depressive type, usually
make a lull recovery and only rarely develop a defect state.

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HISTORY

In 1933, Jacob Kasanin introduced the term schizoaffective disorder to refer to a disorder with
symptoms of both schizophrenia and mood disorders. In patients with this disorder, the onset of
symptoms was sudden and often occurred in adolescence. Patients tended to have a good premorbid level of functioning, and often a specific stressor preceded the onset of symptoms. The
family histories of the patients often included a mood disorder.

EPIDEMIOLOGY

The lifetime prevalence of schizoaffective disorder is less than 1 percent, possibly in the range of
0.5 to 0.8 percent. The depressive type of schizoaffective disorder is more common in older
persons than in younger persons, and the bipolar type is more common in young adults than in
older adults. The prevalence of the disorder has been reported to be lower in men than in women,
particularly married women: the age of onset for women is later than that for men, as in
schizophrenia. Men with schizoaffective disorder are likely to exhibit antisocial behavior and to
have a markedly flat or inappropriate affect.( Kapalan &sadock 2007)

ETIOLOGY

The cause of schizoaffective disorder is unknown. The disorder may be a type of schizophrenia,
a type of mood disorder, or the simultaneous expression of each. Schizoaffective disorder may
also be a distinct third type of psychosis. One that is unrelated to either schizophrenia or a mood
disorder. The most likely possibility is that schizoaffective disorder is a heterogeneous group of
disorders encompassing all of these possibilities.
In current diagnostic systems, patients can receive the diagnosis of schizoaffective disorder if
they fit into one of the following six categories:
(1) Patients with schizophrenia who have mood symptoms:
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(2) Patients with mood disorder who have symptoms of schizophrenia:


(3) Patients with both mood disorder and schizophrenia
(4) Patients with a third psychosis unrelated to schizophrenia and mood disorder:
(5) Patients whose disorder is on a continuum between schizophrenia and mood disorder: and
(6) Patients with some combination of the above.

DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOAFFECTIVE DISORDER


A.

An uninterrupted period of illness during which there is a major mood episode (major
depressive or manic) concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1: Depressed mood.
B.
Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode
(depressive or manic) during the lifetime duration of the illness.
C.
Symptoms that meet criteria for a major mood episode are present for the majority of the
total duration of the active and residual portions of the illness.
D.
The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
Bipolar type: This subtype applies if a manic episode is part of the presentation. Major
depressive episodes may also occur.
Depressive type: This subtype applies if only major depressive episodes are part of the
presentation.
*Among patients aged 18-65. Excludes psychosis due to substance abuse or any other medical
disorder.

CLINICAL FEATURES AND DIAGNOSTIC GUIDELINES ACCORDING TO ICD 10

A diagnosis of schizoaffective disorder should be made only when both definite schizophrenic
and definite affective symptoms are prominent simultaneously, or within a few days of each
other, within the same episode of illness, and when, as a consequence of this, the episode of
illness does not meet criteria for either schizophrenia or a depressive or manic episode. The term
should not be applied to patients who exhibit schizophrenic symptoms and affective symptoms
only in different episodes of illness. It is common, for example, for a schizophrenic patient to
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present with depressive symptoms in the aftermath of a psychotic episode. Some patients have
recurrent schizoaffective episodes, which may be of the manic or depressive type or a mixture of
the two. Others have one or two schizoaffective episodes interspersed between typical episodes
of mania or depression. In the former case, schizoaffective disorder is the appropriate diagnosis.
In the latter, the occurrence of an occasional schizoaffective episode does not invalidate a
diagnosis of bipolar affective disorder or recurrent depressive disorder if the clinical picture is
typical in other respects.
F25.O Schizoaffective disorder, manic type
Clinical features
A disorder in which schizophrenic and manic symptoms are both prominent in the same episode
of illness. The abnormality of mood usually takes the form of elation, accompanied by increased
self-esteem and grandiose ideas, but sometimes excitement or irritability are more obvious and
accompanied by aggressive behaviour and persecutory ideas. In both cases there is increased
energy, over activity, impaired concentration, and a loss of normal social inhibition. Delusions of
reference, grandeur, or persecution may be present, but other more typically schizophrenic
symptoms are required to establish the diagnosis. People may insist, for example, that their
thoughts are being broadcast or interfered with, or that alien forces are trying to control them, or
they may report hearing voices of varied kinds or express bizarre delusional ideas that are not
merely grandiose or persecutory. Careful questioning is often required to establish that an
individual really is experiencing these morbid phenomena, and not merely joking or talking in
metaphors. Schizoaffective disorders, manic type, are usually florid psychoses with an acute
onset; although behaviour is often grossly disturbed, full recovery generally occurs within a few
weeks.
Diagnostic guidelines
There must be a prominent elevation of mood, or a less obvious elevation of mood combined
with increased irritability or excitement. Within the same episode, at least one and preferably two
typically schizophrenic symptoms (as specified for schizophrenia (F20.-), diagnostic guidelines
(a)-(d)) should be clearly present. This category should be used both for a single schizoaffective
episode of the manic type and for a recurrent disorder in which the majority of episodes are
schizoaffective, manic type.
Includes: schizoaffective psychosis, manic type
schizophreniform psychosis, manic type

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F25.1 Schizoaffective disorder, depressive type


Clinical features
A disorder in which schizophrenic and depressive symptoms are both prominent in the same
episode of illness. Depression of mood is usually accompanied by several characteristic
depressive symptoms or behavioural abnormalities such as retardation, insomnia, loss of energy,
appetite or weight, reduction of normal interests, impairment of concentration, guilt, feelings of
hopelessness, and suicidal thoughts. At the same time, or within the same episode, other more
typically schizophrenic symptoms are present; patients may insist, for example, that their
thoughts are being broadcast or interfered with, or that alien forces are trying to control them.
They may be convinced that they are being spied upon or plotted against and this is not justified
by their own behaviour. Voices may be heard that are not merely disparaging or condemnatory
but that talk of killing the patient or discuss this behaviour between themselves. Schizoaffective
episodes of the depressive type are usually less florid and alarming than schizoaffective episodes
of the manic type, but they tend to last longer and the prognosis is less favorable. Although the
majority of patients recover completely, some eventually develop a schizophrenic defect.

Diagnostic guidelines
There must be prominent depression, accompanied by at least two characteristic depressive
symptoms or associated behavioural abnormalities as listed for depressive episode (F32.-);
within the same episode, at least one and preferably two typically schizophrenic symptoms (as
specified for schizophrenia (F20.-), diagnostic guidelines (a)-(d)) should be clearly present. This
category should be used both for a single schizoaffective episode, depressive type, and for a
recurrent disorder in which the majority of episodes are schizoaffective, depressive type.
Includes: schizoaffective psychosis, depressive type
schizophreniform psychosis, depressive type

F25.2 Schizoaffective disorder, mixed type


Disorders in which symptoms of schizophrenia (F20.-) coexist with those of a mixed bipolar
affective disorder (F31.6) should be coded here. Includes: cyclic schizophrenia mixed
schizophrenic and affective psychosis
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified
Includes: schizoaffective psychosis NOS
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DIFFERENTIAL DIAGNOSIS
The psychiatric differential diagnosis includes all the possibilities usually considered for mood
disorders and for schizophrenia. In any differential diagnosis of psychotic disorders, a complete
medical workup should be performed to rule out organic causes for the symptoms. A history of
substance use (with or without positive results on a toxicology screening test) may indicate a
substance-induced disorder. Preexisting medical conditions, their treatment, or both can cause
psychotic and mood disorders. Any suspicion of a neurological abnormality warrants
consideration of a brain scan to rule out anatomical pathology and an electroencephalogram
(EEG) to determine any possible seizure disorders (e.g.. temporal lobe epilepsy). Psychotic
disorder caused by seizure disorder is more common than that seen in the general population. It
tends to be characterized by paranoia, hallucinations, and ideas of reference. Patients with
epilepsy with psychosis are believed to have a better level of function than patients with
schizophrenic spectrum disorders. Better control of the seizures can reduce the psychosis.

COURSE AND PROGNOSIS

Considering the uncertainty and evolving diagnosis of schizoaffective disorder, it is difficult to


determine the long-term course and prognosis. Given the definition of the diagnosis, patients
with schizoaffective disorder might be expected to have a course similar to an episodic mood
disorder, a chronic schizophrenic course, or some intermediate outcome. It has been presumed
that an increasing presence of schizophrenic symptoms predicted worse prognosis. After 1 year,
patients with schizoaffective disorder had different outcomes, depending on whether their
predominant symptoms were affective (better prognosis) or schizophrenic (worse prognosis).

TREATMENT

Pharmacotherapy

Mood stabilizers are a mainstay of treatment for bipolar disorders and are used in the treatment
of patients with schizoaffective disorder. One study that compared lithium with carbamazepine
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(Tegretol) found that carbamazepine was superior for schizoaffective disorder, depressive type.
In practice however, these medications are used extensively alone, in combination with each
other, or with an antipsychotic agent. In manic episodes, patients who are schizoaffective should
be treated aggressively with dosages of a mood stabilizer in the middle to high therapeutic blood
concentration range. As the patient enters maintenance phase the dosage can be reduced to low to
middle range to avoid adverse effects and potential effects on organ systems (e.g., thyroid and
kidney) and to improve ease of use and compliance. Commonly used medications include the
following:
Lithium 300 600mg /day P0
Risperidone 2 10 mg/day P0
Haloperidol 5 100mg /day P0 or 5-20 mg/ day IM
Fluphenazine 25 -50 mg IM
Clozapine 25 - - 450 mg /day P0

Psychosocial Treatment

Patients benefit from a combination of family therapy, social skills training, and cognitive
rehabilitation. Because the psychiatric field has had difficulty deciding on the exact diagnosis
and prognosis of schizoaffective disorder, this uncertainty must be explained to the patient. The
range of symptoms can be vast as patients contend with both ongoing psychosis and varying
mood states. It can be very difficult for family members to keep up with the changing nature and
needs of these patients.

NURSING MANAGEMENT

RISK FOR SELF-DIRECTED OR OTHER-DIRECTED VIOLENCE


Risk Factors
Lack of trust (suspiciousness of others), Panic level of anxiety, Negative role modeling, Rage
reactions, Command hallucinations, Delusional thinking.
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Goals/Objectives
Short-term goals
1. Within [a specified time], client will recognize signs of increasing anxiety and agitation and
report to staff (or other care provider) for assistance with intervention.
2. Client will not harm self or others.
Long-term goal
Client will not harm self or others.
Interventions with selected rationales
1. Maintain low level of stimuli in clients environment (low lighting, few people, simple decor,
low noise level). Anxiety level rises in a stimulating environment. A suspicious, agitated client
may perceive individuals as threatening.
2. Observe clients behavior frequently (every 15 minutes). Do this when carrying out routine
activities so as to avoid creating suspiciousness in the individual. Close observation is necessary
so that intervention can occur if required to ensure client (and others) safety.
3. Remove all dangerous objects from clients environment so that in his or her agitated,
confused state client may not use them to harm self or others.
4. Try to redirect the violent behavior with physical outlets for the clients anxiety (e.g., punching
bag). Physical exercise is a safe and effective way of relieving pent-up tension.
5. Staff should maintain and convey a calm attitude toward client. Anxiety is contagious and can
be transmitted from staff to client.
6. Have sufficient staff available to indicate a show of strength to client if it becomes necessary.
This shows the client evidence of control over the situation and provides some physical security
for staff.
7. Administer tranquilizing medications as ordered by physician. Monitor medication for its
effectiveness and for any adverse side effects. The avenue of the least restrictive alternative
must be selected when planning interventions for a psychiatric client
8. If client is not calmed by talking down or by medication, use of mechanical restraints may
be necessary. Restraints should be used only as a last resort, after all other interventions have
been unsuccessful, and the client is clearly at risk of harm to self or others. Be sure to have
sufficient staff available to assist.
Follow protocol established by the institution. The Joint Commission (formerly the Joint
Commission on Accreditation of Healthcare Organizations [JCAHO]) requires that an in-person
evaluation by a physician or other licensed independent practitioner (LIP) be conducted within 1
hour of the initiation of the restraint or seclusion (The Joint Commission, 2010). The physician
or LIP must reissue a new order for restraints every 4 hours for adults and every 1 to 2 hours for
children and adolescents.
9. The Joint Commission requires that the client in restraints be observed at least every 15
minutes to ensure that circulation to extremities is not compromised (check temperature, color,
pulses); to assist the client with needs related to nutrition, hydration, and elimination; and to
position client so that comfort is facilitated and aspiration is prevented. Continuous one-to one
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monitoring may be necessary for the client who is highly agitated or for whom there is a high
risk of self- or accidental injury. Client safety is a nursing priority.
10. As agitation decreases, assess clients readiness for restraint removal or reduction. Remove
one restraint at a time while assessing clients response. This minimizes risk of injury to client
and staff.
Outcome Criteria
1. Anxiety is maintained at a level at which client feels no need for aggression.
2. Client demonstrates trust of others in his or her environment.
3. Client maintains reality orientation.
4. Client causes no harm to self or others.
SOCIAL ISOLATION
Possible Etiologies
Lack of trust, Panic level of anxiety, Regression to earlier level of development, Delusional
thinking, Past experiences of difficulty in interactions with others, Repressed fears, Unaccepted
social behavior, Alterations in mental status.
Defining Characteristics
Staying alone in room, Uncommunicative, withdrawn, no eye contact, Sad, dull affect,
Inappropriate or immature interests and activities for developmental age or stage, Preoccupation
with own thoughts; repetitive, meaningless actions, Approaching staff for interaction, then
refusing to respond to staffs acknowledgment.
Goals/Objectives
Short-term Goal
Client will willingly attend therapy activities accompanied by trusted staff member within 1
week.
Long-term Goal
Client will voluntarily spend time with other clients and staff members in group activities.
Interventions with selected rationales
1. Convey an accepting attitude by making brief, frequent contacts. An accepting attitude
increases feelings of self-worth and facilitates trust.
2. Show unconditional positive regard. This conveys your belief in the client as a worthwhile
human being.
3. Be with the client to offer support during group activities that may be frightening or difficult
for him or her. The presence of a trusted individual provides emotional security for the client.
4. Be honest and keep all promises. Honesty and dependability promote a trusting relationship.
5. Orient client to time, person, and place, as necessary.
6. Be cautious with touch. Allow client extra space and an avenue for exit if he or she becomes
too anxious. A suspicious client may perceive touch as a threatening gesture.
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7. Administer tranquilizing medications as ordered by physician. Monitor for effectiveness and


for adverse side effects. Antipsychotic medications help to reduce psychotic symptoms in some
individuals, thereby facilitating interactions with others.
8. Discuss with client the signs of increasing anxiety and techniques to interrupt the response
(e.g., relaxation exercises thought stopping). Maladaptive behaviors such as withdrawal and
suspiciousness are manifested during times of increased anxiety.
9. Give recognition and positive reinforcement for clients voluntary interactions with others.
Positive reinforcement enhances self-esteem and encourages repetition of acceptable behaviors.
Outcome Criteria
1. Client demonstrates willingness and desire to socialize with others.
2. Client voluntarily attends group activities.
3. Client approaches others in appropriate manner for one-to one interaction.
INEFFECTIVE COPING
Possible Etiologies
Inability to trust, Panic level of anxiety, Personal vulnerability, Low self-esteem, Inadequate
support systems, Negative role model, Repressed fears, Possible hereditary factor, Dysfunctional
family system.
Defining Characteristics
Suspiciousness of others, resulting in:
Alteration in societal participation
Inability to meet basic needs
Inappropriate use of defense mechanisms

Goals/Objectives
Short-term Goal
Client will develop trust in at least one staff member within 1 week.
Long-term Goal
Client will demonstrate use of more adaptive coping skills as evidenced by appropriateness of
interactions and willingness to participate in the therapeutic community.
Interventions with Selected Rationales
1. Encourage same staff to work with client as much as possible in order to promote development
of trusting relationship.
2. Avoid physical contact. Suspicious clients may perceive touch as a threatening gesture.
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3. Avoid laughing, whispering, or talking quietly where client can see but not hear what is being
said. Suspicious clients often believe others are discussing them, and secretive behaviors
reinforce the paranoid feelings.
4. Be honest and keep all promises. Honesty and dependability promote a trusting relationship.
5. A creative approach may have to be used to encourage food intake (e.g., canned food and own
can opener or family-style meals). Suspicious clients may believe they are being poisoned and
refuse to eat food from the individually prepared tray.
6. Mouth checks may be necessary following medication administration to verify whether client
is swallowing the tablets or capsules. Suspicious clients may believe they are being poisoned
with their medication and attempt to discard the pills.
7. Activities should never include anything competitive. Activities that encourage a one-to-one
relationship with the nurse or therapist are best. Competitive activities are very threatening to
suspicious clients.
8. Encourage client to verbalize true feelings. The nurse should avoid becoming defensive when
angry feelings are directed at him or her. Verbalization of feelings in a nonthreatening
environment may help client come to terms with long-unresolved issues.
9. An assertive, matter-of-fact, yet genuine approach is least threatening and most therapeutic. A
suspicious person does not have the capacity to relate to an overly friendly, overly cheerful
attitude.
Outcome Criteria
1. Client is able to appraise situations realistically and refrain from projecting own feelings onto
the environment.
2. Client is able to recognize and clarify possible misinterpretations of the behaviors and
verbalizations of others.
3. Client eats food from tray and takes medications without evidence of mistrust.
4. Client appropriately interacts and cooperates with staff and peers in therapeutic community
setting.
DISTURBED THOUGHT PROCESSES
Possible Etiologies
Inability to trust, Panic level of anxiety, Stress sufficiently severe to threaten an already weak
ego, possible hereditary factor.
Defining Characteristics
Delusional thinking, Inability to concentrate, Hypervigilance, Altered attention span,
distractibility, Inaccurate interpretation of the environment, Impaired ability to make decisions,
problem-solve, reason, abstract or conceptualize, calculate, Inappropriate social behavior
(reflecting inaccurate thinking), Inappropriate [nonreality-based] thinking.
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Goals/Objectives
Short-term Goal
[By specified time deemed appropriate], client will recognize and verbalize that false ideas occur
at times of increased anxiety.
Long-term Goal
Depending on chronicity of disease process, choose the most realistic long-term goal for the
client:
1. By time of discharge from treatment, clients verbalizations will reflect reality-based thinking
with no evidence of delusional ideation.
2. By time of discharge from treatment, the client will be able to differentiate between delusional
thinking and reality.
Interventions with Selected Rationales
1. Convey your acceptance of clients need for the false belief, but indicate that you do not share
the belief. It is important to communicate to the client that you do not view the idea as real.
2. Do not argue or deny the belief. Arguing with the client or denying the belief serves no useful
purpose, because delusional ideas are not eliminated by this approach, and the development of a
trusting relationship may be impeded.
3. Help the client try to connect the false beliefs to times of increased anxiety. Discuss techniques
that could be used to control anxiety (e.g., deep breathing exercises, other relaxation exercises,
thought-stopping techniques). If the client can learn to interrupt escalating anxiety, delusional
thinking may be prevented.
4. Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. Talk
about real events and real people. Discussions that focus on the false ideas are purposeless and
useless, and may even aggravate the psychosis.
5. Assist and support client in his or her attempt to verbalize feelings of anxiety, fear, or
insecurity. Verbalization of feelings in a nonthreatening environment may help client come to
terms with long-unresolved issues.
Outcome Criteria
1. Verbalizations reflect thinking processes oriented in reality.
2. Client is able to maintain activities of daily living (ADLs) to his or her maximal ability.
3. Client is able to refrain from responding to delusional thoughts, should they occur.

REFERENCES

I. Niraj Ahuja. A short text book of psychiatry. 5 edition. Jaypee Brothers. New Delhi.

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2. Sreevani R. A guide to mental health and psychiatric nursing, 2 edition, 2004, jaypee
brothers. New Delhi.
3. Stuart W. Michele T. Haraia. Principles and practice of psychiatric nursing. 8th edition.
Elsevier . mosby. Philadelphia.
4. Lalitha. K. mental health and psychiatric nursing an Indian perspective. 1 edition. VMG book
house. Bangalorc,2007.
5. Kaplan Ilamid and Sadock Benjamin J. Synopsis of psychiatry 8th edition. William and
Vi1kins.Pennsylvania. 2001.
6. Lopez. J. zober. J. andrason. N. c. New oxford text book of psychiatry. New York: oxford
university. 2000.

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