UNIT 1 SCHIZOPHRENIA: ETIOLOGY,

NEUROCOGNITIVE FUNCTIONING
AND INTERPERSONAL ASPECTS
Structure
1.0 Introduction
1.1 Objectives
1.2 Concept and Description of Schizophrenia
1.2.1 Incidence of Schizophrenia
1.2.2 Characteristics of Schizophrenia
1.2.3 Onset of Schizophrenia
1.2.4 Neurocognitive Explanation of Schizophrenia
1.2.5 Comorbidity
1.2.6 Tests for Schizophrenia

1.3 Etiology of Schizophrenia

1.3.1 Genetics
1.3.2 Prenatal
1.3.3 Fetal Growth
1.3.4 Hypoxia
1.3.5 Other Factors
1.3.6 Infections
1.3.7 Childhood Antecedents

1.4 Substance Use

1.4.1 Cannabis
1.4.2 Amphetamines and other Stimulants
1.4.3 Hallucinogens
1.4.4 Tobacco Use
1.4.5 Social Adversity
1.4.6 Urban City
1.4.7 Close Relationships
1.4.8 Environment
1.4.9 Instinct for Self Respect
1.4.10 Personality Type

1.5 Neurocognitive Functioning Aspects in Schizophrenia

1.6 Treatment of Schizophrenia
1.6.1 Hospitalisation
1.6.2 Medication
1.6.3 Cognitive Behavioural Therapy
1.6.4 Metacognitive Training
1.6.5 Family Therapy or Education

1.7 Unit End Questions

1.8 Let Us Sum Up
1.9 Suggested Readings
5
Schizophrenia and Other
Psychotic Disorders 1.0 INTRODUCTION
This unit deals with schizophrenia and focuses on neuropsychological aspects. The
unit begins with the concept and description of schizophrenia and provides the incidence
and prevalence rate of schizophrenia in India and abroad. It explains the characteristics
of schizophrenia and indicates the onset of the disorder to be in the teens and adolescent
years to young adulthood. The comorbidity of certain other disorders along with
schizophrenia are discussed. Then we present a few important tests to clearly diagnose
the schizophrenic disorder. The next section deals with the etiology of schizophrenia in
which we discuss the role of genetics, prenatal factors, fetal growth abnormalities, lack
of oxygen andsome of the important childhood antecedents. The causes then present
the role of substance euse in schizophrenia and tin this we discuss the role of cannabis,
amphetamines, hallucinogens, tobacco etc. Social fac\tors, urbanicity, relationships
within family and personality types are also considered as causes in the onset of
schizophrenia. Then we discuss the neurocognitive functioning of schizophrenia followed
by treatment of schizophrenic disorder. The treat ment includes hospitalisation,
medicines, cognitive behaviour therapy and family therapy.

1.1 OBJECTIVES
On completing this unit, you will be able to :
 Define schizophrenia and describe the characteristic features;
 Explain the etiology of schizophrenia;
 Describe how substance use cause schizophrenic symptoms;
 Explain the neurocognitive functioning aspects of schizophrenia;
 Elucidate the treatment of schizophrenia; and
 Analyse the importance of various psychological therapies.

1.2 CONCEPT AND DESCRIPTION OF

SCHIZOPHRENIA
Schizophrenia is a severe, psychotic disorder. People who have it may hear voices, see
things that are not there or believe that others are reading or controlling their minds. In
men, symptoms usually start in the late teens and early 20s. They include hallucinations,
such as visual hallucinations ( seeing things which are not there), and auditory
hallucinations (hearing things which are not present), and delusions such as false beliefs
that others are plotting or conspiring against them while actually there is no such thing.

1.2.1 Incidence of Schizophrenia

The incidence of schizophrenia is estimated to be one percent to one and a half percent
of the U.S. population being diagnosed with it over the course of their lives. In India,
according to NIMH, it is estimated that 4.3 to 8.7 million people (a rough estimate
based on the population) suffer from schizophrenia. According to Barua et al (2006),
the prevalence rate of schizophrenia in India is 1%.

1.2.2 Characteristics of Schizophrenia

While there is no known cure for schizophrenia, it is a treatable disorder. Most of those
6 afflicted by schizophrenia respond to drug therapy, and many are able to lead productive
and fulfilling lives. It is characterised by a constellation of distinctive and predictable Schizophrenia: Etiology,
Neurocognitive
symptoms. The symptoms that are most commonly associated with the disease are Functioning and
called positive symptoms, that denote the presence of grossly abnormal behaviour. Interpersonal Aspects
These include thought disorder, delusions, and hallucinations.
Thought disorder is the diminished ability to think clearly and logically. Often it is
manifested by disconnected and nonsensical language that renders the person with
schizophrenia incapable of participating in conversation, contributing to the person’s
alienation from his family, friends, and society.
Delusions are common among individuals with schizophrenia. An affected person may
believe that he is being conspired against (called “paranoid delusion”). Broadcasting,
describes a type of delusion in which the individual with this illness believes that his
thoughts can be heard by others.
Hallucinations are perceptual disorder, in which one could suffer from auditory
hallucination, visual hallucination and tactile hallucination. Sometime the voices that the
schizophrenic hears may describe the person’s actions, warn him of danger or tell him
what to do. At times the individual may hear several voices carrying on a conversation.
Less obvious than the “positive symptoms” but equally serious are the deficit or negative
symptoms that represent the absence of normal behaviour. These include flat or blunted
affect (i.e. lack of emotional expression), apathy, and social withdrawal).
Schizophrenia is a mental disorder characterised by a disintegration of thought processes
and of emotional responsiveness. It most commonly manifests as auditory hallucinations,
paranoid or bizarre delusions, or disorganised speech and thinking, and it is accompanied
by significant social or occupational dysfunction.

1.2.3 Onset of Schizophrenia

It can affect anyone at any point in life, it is somewhat more common in those persons
who are genetically predisposed to the disorder. The first psychotic episode generally
occurs in late adolescence or early adulthood. The probability of developing
schizophrenia as the offspring of two parents, neither of whom has the disease, is 1
percent. The probability of developing schizophrenia as the offspring of one parent
with the disease is approximately 13 percent. The probability of developing schizophrenia
as the offspring of both parents with the disease is approximately 35%. Persons with
schizophrenia develop the disease between 16 and 25 years of age.
This disorder has its onset around adolescent years to 20s to early 30s. This disorder
makes the person behave in the weirdest manner that persons with this disorder are
also stigmatized. As generally thought to be, schizophrenia is not a split personality, it is
a rare and very different disorder. Like cancer and diabetes, schizophrenia has a
biological basis. It is not caused by bad parenting or personal weaknesses.
Onset is uncommon after age 30, and rare after age 40. In the 16-25 year old age
group, schizophrenia affects more men than women. In the 25-30 year old group, the
incidence is higher in women than in men.
The onset of symptoms typically occurs in young adulthood, with a global lifetime
prevalence of about 0.3–0.7%. Diagnosis is based on observed behaviour and the
patient’s reported experiences.

1.2.4 Neurocognitive Explanations of Schizophrenia

Increasingly, neuro cognitive paradigms are used to study patients with schizophrenia. 7
Schizophrenia and Other With such paradigms, the cognitive abnormalities in schizophrenia are characterised by
Psychotic Disorders
means of experimental and clinical tests. These techniques have indicated that some
types of cognitive impairment are not only reliably present in schizophrenia, but are also
central and enduring features of the disorder. This focuses on certain recent advances in
i) characterising the precise nature of cognitive impairments in schizophrenia,
ii) understanding the implications of these for treatment, given the course and
relationship to outcome of these variables, and
iii) on novel applications of neuro cognitive approaches to the genetics of schizophrenia.

1.2.5 Comorbidity
Genetics, early environment, neurobiology, and psychological and social processes
appear to be important contributory factors; some recreational and prescription drugs
appear to cause or worsen symptoms. Current research is focused on the role of
neurobiology, although no single isolated organic cause has been found.
The many possible combinations of symptoms have triggered debate about whether
the diagnosis represents a single disorder or a number of discrete syndromes. Despite
the etymology of the term from the Greek roots skhizein (to split) and phrēn, phren-
(mind), schizophrenia does not imply a “split mind” and it is not the same as dissociative
identity disorder, also known as “multiple personality disorder” or “split personality” a
condition with which it is often confused in public perception.
The disorder is thought mainly to affect cognition, but it also usually contributes to
chronic problems with behaviour and emotion. People with schizophrenia are likely to
have additional (comorbid) conditions, including major depression and anxiety disorders.
The lifetime occurrence of substance abuse is almost 50%. Social problems, such as
long-term unemployment, poverty and homelessness, are common. The average life
expectancy of people with the disorder is 12 to 15 years less than those without, the
result of increased physical health problems and a higher suicide rate (about 5%).
It is possible that nearly every cognitive function of a schizophrenic patient is impaired,
and to an equivalent degree three functions play a role that is early descriptions of the
clinical phenomenology of schizophrenia emphasized impairment of volitional attention.
This clinical observation has been amply supported by many years of experimental
study with the use of a wide variety of tasks.

1.2.6 Tests for Schizophrenia

Recent models have sharpened the lines between selective attention, shifting attention,
and biasing for and encoding relevant target information. We investigate some of these
functions by examining three tasks, viz.,
i) the Continuous Performance Test (CPT),
ii) the Covert Visual Orienting test, and the
iii) Stroop Test.
The classic test of selective attention is the Stroop color word task, in which a word
(e.g., red) can be printed in incongruent colors (e.g., green). Depending on instructions,
the task is either to name the actual word or name the ink color in which the word is
written.
The attentional task requires the subject to focus selectively on one dimension of the
8 stimulus and ignore or inhibit contextually inappropriate response tendencies. Normal
subjects are slowed when they have to name a color of ink that is incongruent with the Schizophrenia: Etiology,
Neurocognitive
word because they have to inhibit their over learned tendency of reading the word. Functioning and
Interpersonal Aspects
Schizophrenic patients may have differential problems on this task in reaction time or
accuracy, a finding that has been taken to suggest that they have disproportionate difficulty
in inhibiting over learned tendencies (of reading the word), and may be susceptible to
failure in conditions of cognitive conflict more generally, because they are unable to use
the contextual information appropriately.
Secondly Memory impairment is often the most striking feature of neuro cognitive
impairment in schizophrenia. Newer work has sought to determine if patients with
schizophrenia have qualitative abnormalities in specific stages of mnemonic processing.
Toward this end, Elvevaag and colleagues conducted an encoding study in which subjects
had to state whether the letter a was present in a word (shallow level)or make a
decision as to whether the word represented a living thing or not (deep level).
Much previous work has demonstrated that words are recalled better when they are
encoded deeply. Preliminary results indicated that although patients’ performance was
worse than that of controls, they showed the same benefit of deep encoding. In other
words, although impairment in any given cognitive process may exact only a small cost
in social and vocational functioning, a constellation of impairments may be disabling and
result in the emergence of psychosis. Thus, understanding the genetic architecture of
individual processes may well be critical.
Self Assessment Questions
1) Define schizophrenia and bring out its important features.
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2) What is the prevalence and incidence rate of schizophrenia?
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3) Describe the onset of schizophrenia.
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4) Give the neurocognitive explanations of schizophrenia.
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Schizophrenia and Other .....................................................................................................................
Psychotic Disorders
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5) What is meant by comorbidity? What are the disorders associated with
schizophrenia?
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6) Describe the tests for schizophrenia.
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1.3 ETIOLOGY OF SCHIZOPHRENIA

The causes of schizophrenia have been the subject of much debate, with various factors
proposed and discounted or modified. The language of schizophrenia research under
the medical model is scientific. Such studies suggest that genetics, prenatal development,
early environment, neurobiology and psychological and social processes are important
contributory factors.
Current psychiatric research into the development of the disorder is often based on a
neurodevelopmental model (proponents of which see schizophrenia as a syndrome.
However, schizophrenia is diagnosed on the basis of symptom profiles. Neural correlates
do not provide sufficiently useful criteria “Current research into schizophrenia has
remained highly fragmented, much like the clinical presentation of the disease itself”

1.3.1 Genetics
Genetic vulnerability and environmental factors can act in combination to result in diagnosis
of schizophrenia. Research suggests that genetic vulnerability to schizophrenia is multi
factorial, caused by interactions of several genes.
Both individual twin studies and meta analyses of twin studies estimate the heritability
of risk for schizophrenia to be approximately 80%. Concordance rates between
monozygotic twins was close to 50%, whereas dizygotic twins was 17%. Adoption
studies have also indicated a somewhat increased risk in those with a parent with
schizophrenia even when raised apart. Studies suggest that the phenotype is genetically
influenced but not genetically determined. Also the variants in genes are generally within
the range of normal human variation and have low risk associated with them each
individually. Some interact with each other and with environmental risk factors and
that they may not be specific to schizophrenia.

1.3.2 Prenatal
It is well established that obstetric complications or events are associated with an
increased chance of the child later developing schizophrenia, although overall they
10 constitute a non specific risk factor with a relatively small effect.
Obstetric complications occur in approximately 25 to 30% of the general population Schizophrenia: Etiology,
Neurocognitive
and the vast majority do not develop schizophrenia, and likewise the majority of Functioning and
individuals with schizophrenia have not had a detectable obstetric event. Interpersonal Aspects

Nevertheless, the increased average risk is well replicated, and such events may moderate
the effects of genetic or other environmental risk factors. The specific complications or
events most linked to schizophrenia, and the mechanisms of their effects, are still under
examination.
One epidemiological finding is that people diagnosed with schizophrenia are more likely
to have been born in winter or spring. However, the effect is not large. Explanations
have included a greater prevalence of viral infections at that time, or a greater likelihood
of vitamin D deficiency. A similar effect (increased likelihood of being born in winter
and spring) has also been found with other, healthy populations, such as chess players.

1.3.3 Fetal Growth

Lower than average birth weight has been one of the most consistent findings, indicating
slowed fetal growth possibly mediated by genetic effects. Almost any factor adversely
affecting the fetus will affect growth rate, however, so the association has been described
as not particularly informative regarding causation. In addition, the majority of birth
cohort studies have failed to find a link between schizophrenia and low birth weight or
other signs of growth retardation.

1.3.4 Hypoxia
It has been hypothesized since the 1970s that brain hypoxia (low oxygen levels) before,
at or immediately after birth may be a risk factor for the development of schizophrenia.
Hypoxia is now being demonstrated as relevant to schizophrenia in animal models,
molecular biology and epidemiology studies. One study in Molecular Psychiatry was
able to differentiate 90% of schizophrenics from controls based on hypoxia and
metabolism.
Hypoxia has been recently described as one of the most important of the external
factors that influence susceptibility, although studies have been mainly epidemiological.
Such studies place a high degree of importance on hypoxic influence. Fetal hypoxia, in
the presence of certain unidentified genes, has been correlated with reduced volume of
the hippocampus, which is in turn correlated with schizophrenia.
Although most studies have interpreted hypoxia as causing some form of neuronal
dysfunction or even subtle damage, it has been suggested that the physiological hypoxia
that prevails in normal embryonic and fetal development, or pathological hypoxia or
ischemia, may exert an effect by regulating or deregulating genes involved in
neurodevelopment.

1.3.5 Other Factors

There is an emerging literature on a wide range of prenatal risk factors, such as prenatal
stress, intrauterine (in the womb) malnutrition, and prenatal infection. Increased paternal
age has been linked to schizophrenia, possibly due to “chromosomal aberrations and
mutations of the aging germline.”
Maternal-fetal rhesus or genotype incompatibility has also been linked, via increasing
the risk of an adverse prenatal environment. Also, in mothers with schizophrenia, an
increased risk has been identified via a complex interaction between maternal genotype,
11
Schizophrenia and Other maternal behaviour, prenatal environment and possibly medication and socio-economic
Psychotic Disorders
factors.
There may be an association between celiac disease (gluten intolerance) and
schizophrenia in a small proportion of patients, though large randomized controlled
trials and epidemiological studies will be needed before such an association can be
confirmed.
Withdrawal of gluten from the diet is an inexpensive measure which may improve the
symptoms in a small (  3%) number of schizophrenic patients.

1.3.6 Infections
Numerous viral infections, in utero or in childhood, have been associated with an
increased risk of later developing schizophrenia.
Influenza has long been studied as a possible factor. A 1988 study found that individuals
who were exposed to the Asian flu as second trimester fetuses were at increased risk of
eventually developing schizophrenia. This result was corroborated by a later British
study of the same pandemic, but not by a 1994 study of the pandemic in Croatia. A
Japanese study also found no support for a link between schizophrenia and birth after
an influenza epidemic.
Polio, measles, varicella-zoster, rubella, herpes simplex virus type 2, maternal genital
infections, Borna disease virus, and more recently Toxoplasma gondii, have been
correlated with the later development of schizophrenia. Psychiatrists E. Fuller Torrey
and R.H. Yolken have hypothesized that the latter, a common parasite in humans,
contributes to some, if not many, cases of schizophrenia.

1.3.7 Childhood Antecedents

In general, the antecedents of schizophrenia are subtle and those who will go on to
develop schizophrenia do not form a readily identifiable subgroup, which would lead
to identification of a specific cause. Average group differences from the norm may be in
the direction of superior as well as inferior performance.
Overall, birth cohort studies have indicated subtle nonspecific behavioural features,
some evidence for psychotic like experiences (particularly hallucinations), and various
cognitive antecedents. There have been some inconsistencies in the particular domains
of functioning identified and whether they continue through childhood and whether they
are specific to schizophrenia.
A prospective study found average differences across a range of developmental domains,
including reaching milestones of motor development at a later age, having more speech
problems, lower educational test results, solitary play preferences at ages four and six,
and being more socially anxious at age 13.

1.4 SUBSTANCE USE

The relationship between schizophrenia and drug use is complex, meaning that a clear
causal connection between drug use and schizophrenia has not been found. There is
strong evidence that using certain drugs can trigger either the onset or relapse of
schizophrenia in some people. It may also be the case, however, that people with
schizophrenia use drugs to overcome negative feelings associated with both the commonly
prescribed antipsychotic medication and the condition itself, where negative emotion,
12 paranoia and anhedonia are all considered to be core features.
The rate of substance use is known to be particularly high in this group. In a recent Schizophrenia: Etiology,
Neurocognitive
study, 60% of people with schizophrenia were found to use substances and 37% would Functioning and
be diagnosable with a substance use disorder. Interpersonal Aspects

1.4.1 Cannabis
There is some evidence that cannabis use can contribute to schizophrenia. Some studies
suggest that cannabis is neither a sufficient nor necessary factor in developing
schizophrenia, but that cannabis may significantly increase the risk of developing
schizophrenia and may be, among other things, a significant causal factor. Nevertheless,
some previous research in this area has been criticised as it has often not been clear
whether cannabis use is a cause or effect of schizophrenia. To address this issue, a
recent review of studies from which a causal contribution to schizophrenia can be
assessed has suggested that cannabis statistically doubles the risk of developing
schizophrenia on the individual level, and may, assuming a causal relationship, be
responsible for up to 8% of cases in the population.

1.4.2 Amphetamines and other Stimulants

As amphetamines trigger the release of dopamine and excessive dopamine function is
believed to be responsible for many symptoms of schizophrenia (known as the dopamine
hypothesis of schizophrenia), amphetamines may worsen schizophrenia symptoms. In
addition, amphetamines are known to cause a stimulant psychosis in otherwise healthy
individuals that superficially resembles schizophrenia, and may be misdiagnosed as such
by some healthcare professionals.

1.4.3 Hallucinogens
Drugs such as ketamine, PCP, and LSD have been used to mimic schizophrenia for
research purposes. Using LSD and other psychedelics as a model has now fallen out of
favour with the scientific research community, as the differences between the drug induced
states and the typical presentation of schizophrenia have become clear. The dissociatives
ketamine and PCP, however, are still considered to produce states that are remarkably
similar however, and are considered to be even better models than stimulants since they
produce both positive and negative symptoms.

1.4.4 Tobacco Use

People with schizophrenia tend to smoke significantly more tobacco than the general
population. The rates are exceptionally high amongst institutionalised patients and
homeless people. In a UK census from 1993, 74% of people with schizophrenia living
in institutions were found to be smokers A 1999 study that covered all people with
schizophrenia in Nithsdale, Scotland found a 58% prevalence rate of cigarette smoking,
to compare with 28% in the general populatio
Despite the higher prevalence of tobacco smoking, people diagnosed with schizophrenia
have a much lower than average chance of developing and dying from lung cancer.
While the reason for this is unknown, it may be because of a genetic resistance to the
cancer, a side effect of drugs being taken, or a statistical effect of increased likelihood
of dying from causes other than lung cancer.
A 2003 study of over 50,000 Swedish conscripts found that there was a small but
significant protective effect of smoking cigarettes on the risk of developing schizophrenia
later in life. While the authors of the study stressed that the risks of smoking far outweigh
these minor benefits, this study provides further evidence for the ‘self-medication’ theory
13
Schizophrenia and Other of smoking in schizophrenia and may give clues as to how schizophrenia might develop
Psychotic Disorders
at the molecular level.

1.4.5 Social Adversity

The chance of developing schizophrenia has been found to increase with the number of
adverse social factors (e.g. indicators of socio-economic disadvantage or social
exclusion) present in childhood. Stressful life events generally precede the onset of
schizophrenia. A personal or recent family history of migration is a considerable risk
factor for schizophrenia, which has been linked to psychosocial adversity, social defeat
from being an outsider, racial discrimination, family dysfunction, unemployment and
poor housing conditions.
Childhood experiences of abuse or trauma are risk factors for a diagnosis of schizophrenia
later in life. Recent large-scale general population studies indicate the relationship is a
causal one, with an increasing risk with additional experiences of maltreatment although
a critical review suggests conceptual and methodological issues require further research
There is some evidence that adversities may lead to cognitive biases and/or altered
dopamine neurotransmission, a process that has been termed “sensitisation”.
Specific social experiences have been linked to specific psychological mechanisms and
psychotic experiences in schizophrenia. In addition, structural neuroimaging studies of
victims of sexual abuse and other traumas have sometimes reported findings similar to
those sometimes found in psychotic patients, such as thinning of the corpus callosum,
loss of volume in the anterior cingulate cortex, and reduced hippocampal volume.

1.4.6 Urban City

A particularly stable and replicable finding has been the association between living in an
urban environment and the development of schizophrenia, even after factors such as
drug use, ethnic group and size of social group have been controlled for.[115] A recent
study of 4.4 million men and women in Sweden found a 68%–77% increased risk of
diagnosed psychosis for people living in the most urbanized environments, a significant
proportion of which is likely to be described as schizophrenia

1.4.7 Close Relationships

Evidence is consistent that negative attitudes from others increase the risk of schizophrenia
relapse, in particular critical comments, hostility, authoritarian, and intrusive or controlling
attitudes (termed ‘high expressed emotion’ by researchers).

1.4.8 Environment
Pollack and Malzberg studied 175 patients of this disease and reached to the conclusion
that environment plays a bigger part in creating this disease than does heredity, and so
psychologist today refutes the importance of environment in causing of schizophrenia.

1.4.9 Instinct for Self-respect

According to McDougall, when the patient is unable to find proper and desirable
expression for his instincts of self-respect, he becomes a prey to schizophrenia.

1.4.10 Personality Type

It is the opinion of some psychologists that only a certain personality type is susceptible
to schizophrenic tendencies, primarily the introverted type of individual. But this concept
14
of the personality type being more prone to schizophrenia has also not found much of Schizophrenia: Etiology,
Neurocognitive
the following among the thinkers. Functioning and
Interpersonal Aspects
1.5 NEUROCOGNITIVE FUNCTIONING ASPECTS
IN SCHIZOPHRENIA
In neuropsychology, that is, inferring regional brain dysfunction based on poor
performance on putatively localising neuropsychological tests. On the basis of such an
approach, various authors have concluded that schizophrenia is characterisedby cognitive
test profiles indicative of dysfunction of the frontal lobe, temporal lobe, left or right
hemisphere, basal ganglia, etc. This lack of consensus may reflect the heterogeneity of
schizophrenia, and may also be a result of the relatively poor localising ability of many
standard neuropsychological instruments. A variety of brain regions and associated
cognitive functions have thus been implicated in the psychopathology that characterises
schizophrenia.
In general, the strongest camps to emerge have been those that claim a disproportionate
impairment of memory functioning and relativelyselective executive dysfunction. Others
have reported more widespread neuropsychological dysfunction. An extreme case is
put by Meehl who stated that impaired cognitive test performance in patients with
schizophrenia may be an epiphenomenon, for example, reflecting lack of motivation or
distraction by hallucinations. In order to convince skeptics that the neuropsychological
impairment is important, one would have to demonstrate a clear relationship between
cognitive test performance and ‘real-life’ functional outcome.
An important review of this area was published by Green (1996), who evaluated studies
that used cognitive measures as predictors and correlates of functional outcome. The
most consistent finding to emerge was that verbal memory functioning was associated
with all types of functional outcome. It was observed that verbal memory showed the
greatest impairment in the meta-analysis whereas sustained attention or vigilance was
found to be related to social problem solving and skill acquisition.
Interestingly, psychotic symptoms werenot significantly associated with outcome measures
in any of the studies that were reviewed. Green (1996) concluded that deficiencies in
verbal memory and vigilance may prevent patients from attaining optimal adaptation
and hence may act as rate limiting factors in terms of rehabilitation. It is interesting to
observe that where the patients showed symptomatic improvement with clozapine
treatment, there was no associated improvement in neuropsychologicalfunctioning.
Velligan et al (1997) confirmed a poor correlation betweensymptomatology and ability
to perform daily living tasks. However, cognitive impairment predicted over 40% of the
variance in scores on a functional needs assessment rating scale.
Addington & Addington (1999) used a novel video taped measure of interpersonal
problem solving skills. In a study of 80 out patients with schizophrenia, they found that
better cognitive flexibility and verbal memorywere positively associated with interpersonal
problem solving ability.
In summary all these studies taken together, strongly support the view that cognitive
impairment in schizophrenia is directly related to social deficits and functional outcome
for many patients.
Schizophrenia symptoms may more clearly relate to disordered patterns of information
processing. Liddle & Morris (1991) conducted a seminal study in this area where they
15
Schizophrenia and Other assessed a group of patients with chronic schizophrenia using a battery of
Psychotic Disorders
neuropsychological tests allegedlysensitive to frontal lobe dysfunction.
Signs and symptoms were clustered into three syndromes:
 psychomotor poverty,
 disorganisation and
 reality distortion.
Scores for the disorganisation syndrome were associated with impairment on tests that
required the subject to inhibit a well established but inappropriate response. Ratings for
the psychomotor poverty syndrome were found to be associated with slowness of mental
activity.
More recently, Baxter & Liddle (1998) confirmed that the psychomotor poverty
syndrome was associated with psychomotor slowing, and disorganisationwas associated
with impaired performance on the Stroop Attentional Conflict task, but not with other
tests of cognitive inhibition.
This led the authors to conclude that the disorganisation syndrome might be associated
with a specific difficulty in suppressing irrelevant verbal responses. This approach is
appealing, because it tries to integrate neuropsychology with the clinical features of
schizophrenia. Pursuing this approach to a more specific level would result in an attempt
to explain specific signs or symptoms in terms of aberrant information processing.
As an illustration of this approach, McKenna (1991) proposed that delusions may arise
as a consequence of a dysfunctional semantic memory system. Again, this hypothesis
has intuitive appeal, as delusions by definition must represent false belief, knowledge.
However, efforts to try to provide convincing evidence of a causal relationship between
a specific neuropsychological abnormality and a particular sign or symptom have, as
yet, been disappointing.
The resulting cognitive data were subjected to cluster analysis and five cognitive clusters
emerged:
 selective executive dysfunction;
 normative function;
 executive and motor deficits;
 dementia/multi-focal disturbance; and
 relatively selective motor deficits.
Heinrichs & Awad (1993) proposed that cluster analysis of cognitive test data may thus
have promise in reducing and clarifying the heterogeneity of schizophrenia, and concluded
that several patterns of neurocognitive dysfunction may underlie schizophrenia, thus
contributing to the heterogeneity of the illness and its variable functional outcome.
Frith (1992) has also proposed a fascinating theoretical model, where he relates specific
signs and symptoms to particular information processing abnormalities. For example,
he proposes that the inability to generate spontaneous (willed) intentions can lead to
poverty of action, perseveration and inappropriate action. In contrast, the inability to
monitor the beliefs and intentions of others can lead to delusions of reference, paranoid
delusions, certain kinds of incoherence and third-person hallucinations.
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 Schizophrenia: Etiology,
Self Assessment Questions Neurocognitive
Functioning and
1) Discuss the etiology of schizophrenia. Interpersonal Aspects

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2) What are the childhood antecedents that cause schizophrenia?
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3) Discuss social adversity and urbanicity as causes of schizophrenia.
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4) Discuss etiology of schizophrenia in terms of substance use.
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5) Describe the neurocognitive functioning aspects of schizophrenia.
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1.6 TREATMENT OF SCHIZOPHRENIA

1.6.1 Hospitalisation
Hospitalisation may occur with severe episodes of schizophrenia. This can be voluntary
or (if mental health legislation allows it) involuntary (called civil or involuntary
commitment). Long term inpatient stays are now less common due to the policy of
deinstitutionalisation, yet we still have large number of patients admitted to institutions
for longer period of stay .
17
Schizophrenia and Other Following (or in lieu of) a hospital admission, support services available can include
Psychotic Disorders
drop in centers, visits from members of a community mental health team or Assertive
Community Treatment team, supported employment and patient led support groups.

1.6.2 Medication
The mainstay of psychiatric treatment for schizophrenia is an antipsychotic medication.
These can reduce the “positive” symptoms of psychosis. Most antipsychotics take
around 7–14 days to have their main effect. Risperidone (trade name Risperdal) is a
common atypical antipsychotic medication.
Treatment was revolutionized in the mid 1950s with the development and introduction
of the first antipsychotic chlorpromazine. Others such as haloperidol and trifluoperazine
soon followed.
Though expensive, the newer atypical antipsychotic drugs are usually preferred for
initial treatment over the older typical antipsychotics; they are often better tolerated and
associated with lower rates of tardive dyskinesia, although they are more likely to induce
weight gain and obesity-related diseases. Of the atypical antipsychotics, olanzapine
and clozapine are the most likely to induce weight gain. The effect is more pronounced
if high doses of olanzapine are used.[11] Smaller amounts of weight gain are induced by
risperidone and quetiapine. Ziprasidone and aripiprazole are considered to be weight
neutral antipsychotics.
It remains unclear whether the newer antipsychotics reduce the chances of developing
neuroleptic malignant syndrome, a rare but serious and potentially fatal neurological
disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs.
In combination with drug treatment, Psychosocial and Psychotherapy are also widely
recommended and used in the treatment of schizophrenia.

1.6.3 Cognitive Behavioural Therapy (CBT)

CBT is used to target specific symptoms and improve related issues such as the therapy
advanced from its initial applications in the mid 1990s, more recent reviews clearly
show CBT is an effective treatment for the psychotic symptoms of schizophrenia.
Another approach is cognitive remediation therapy, a technique aimed at remediating
the neurocognitive deficits sometimes present in schizophrenia. Based on techniques of
neuropsychological rehabilitation, early evidence has shown it to be cognitively effective,
resulting in the improvement of previous deficits in psychomotor speed, verbal memory,
nonverbal memory, and executive function, such improvements being related to
measurable changes in brain activation as measured by fMRI.
A similar approach known as cognitive enhancement therapy, which focuses on social
cognition as well as neurocognition, has shown efficacy. CBT, an evidenced based
practice, is now offered in community mental health agencies and hospitals.

1.6.4 Metacognitive Training

In view of a many empirical findings suggesting deficits of metacognition (thinking about
one’s thinking, reflecting upon one’s cognitive process) in patients with schizophrenia,
metacognitive training (MCT) is increasingly adopted as a complementary treatment
approach.

18
MCT aims at sharpening the awareness of patients for a variety of cognitive biases (e.g. Schizophrenia: Etiology,
Neurocognitive
jumping to conclusions, attributional biases, over-confidence in errors), which are Functioning and
implicated in the formation and maintenance of schizophrenia positive symptoms Interpersonal Aspects
(especially delusions), and to ultimately replace these biases with functional cognitive
strategies.

1.6.5 Family Therapy or Education

This addresses the whole family system of an individual with a diagnosis of schizophrenia,
has been consistently found to be beneficial, at least if the duration of intervention is
longer term. Aside from therapy, the impact of schizophrenia on families and the burden
on careers has been recognised, with the increasing availability of self help books on
the subject.
There is also some evidence for benefits from social skills training, although there have
also been significant negative findings. Some studies have explored the possible benefits
of music therapy and other creative therapies.

1.7 UNIT END QUESTIONS

1) Define the etiology for schizophrenia from genetic, hereditary and biological point
of view?
2) What are the environmental factors that cause schizophrenia?
3) How neurofunctioning deficts affects the life of individual and cause schizophrenia?
4) Discuss some of the treatment approaches to schizophrenia.
5) Discuss hospitalisation and medication as treatment techniques for schizophrenia.
6) Describe family therapy and education as important treatment programme for
schizophrenia.

1.8 LET US SUM UP

In the lay imagination, schizophrenic patients experience problems in living because
they are divided against themselves, out of touch with reality, and disorganised. The
view of scientists, once not altogether different, has changed.
Not only have the symptoms been defined and codified, but the neurobiological
underpinnings of the disorder have begun to be described. Emerging also is a view in
which cognitive impairments may be a relatively central feature of the disorder.
Cognitive impairments are involved in the genetic etiology of schizophrenia. They seem
enduring in that they are present for much of the clinical history and are associated with
outcome. Cognitive impairments also may have a relatively well delineated profile in
which executive, memory, and attentional deficits are prominent.
As explained, schizophrenia is very disabling. But as research progresses treatment is
slowly but surely becoming more and more effective. Fewer patients have to be kept in
hospitals and damage to the brain is not as severe.
Scientists discovered the effects of oestrogen, and learned it could be used as a medicine
(though long term medications using oestrogen have side effects). They discovered age
and gender differences, and learned that there were structural changes even at a cellular
level. 19
Schizophrenia and Other In conclusion, though schizophrenia is disabling and sometimes even deadly, modern
Psychotic Disorders
science has made many medical breakthroughs, and perhaps, if it is even possible,
scientists may discover a complete or partial cure.

1.9 SUGGESTED READINGS

Allen, Thomas E., Liebman, Mayer C., Park, Lee Crandall, and Wimmer, William C.
(2001). A Primer on Metal Disorders. Lanham, Scarecrow Press, Maryland.
Kolb, Bryan, and Whishaw, Ian Q. (1998). Fundamentals of Human
Neuropsychology 4th ed. WH Freeman. , New York.
Michael Gelder, Richard Mayou, and Philip Cowen. (2001). The Shorter Oxford
Textbook of Psychiatry. 4th edition. Oxford University Press, New York.

20
UNIT 2 PARANOID AND DELUSIONAL
DISORDER
Structure
2.0 Introduction
2.1 Objectives
2.2 Concept of Paranoia
2.2.1 Definition of Paranoia
2.2.2 Characteristic Features of Paranoia
2.2.3 Symptoms of Paranoia
2.2.4 Kinds of Paranoia

2.3 Causes of Paranoia

2.3.1 Homosexual Fixation
2.3.2 Feelings of Inferiority
2.3.3 Emotional Complex
2.3.4 Personality Type
2.3.5 Heredity
2.3.6 Biological
2.3.7 Environmental / Psychological
2.3.8 Dysfunctional Cognitive Processing
2.3.9 Medical Causes
2.3.10Associated Mental Illnesses
2.3.11Substance Abuse

2.4 Delusional Disorder

2.4.1 Characteristic Features
2.4.2 Types of Delusional Disorder
2.4.3 Delusions of Grandeur
2.4.4 Motivated or Defensive Delusions

2.5 Delusions and Other Disorders

2.6 Treatment Approaches to Paranoia and Delusional Disorder
2.6.1 Treatment and Cure
2.6.2 Psychoanalytic Method
2.6.3 Cognitive Behavioural Therapy (CBT)
2.6.4 Drug Therapy
2.6.5 Combining Pharmacotherapy with Cognitive Therapy
2.6.6 Psychotherapy
2.6.7 Prognosis of Paranoia and Delusional Disorder

2.7 Let Us Sum Up

2.8 Unit End Questions
2.9 Suggested Readings and References

2.0 INTRODUCTION
This unit deals with paranoia and delusional disorder. We start with the concept of
paranoia, define paranoia and describe the characteristic features of the same. Then we 21
Schizophrenia and Other delineate the symptoms of paranoia and the kinds of paranoia that are obtained in this
Psychotic Disorders
disorder. This is followed by Causes of paranoia wherein we deal with various factors
including feelings of inferiority, emotional complex, personality type, hereditary factors,
biological factors, environmental and psychological factors. We also mention the medical
causes, other mental illnesses and substance abuse as a cause. Then we discuss delusional
disorder. Delineating the characteristic features of this disorder we deal with the various
types of delusional disorders especially the grandiose, erotomaniac etc., and then deal
with the motivated or defensive delusions. Since delusion are obtained in various other
psychiatric disorders, these aspects are then considered followed by the treatment
approach to the paranoia and delusional disorders. We end up with the prognosis of
these disorders.

2.1 OBJECTIVES
On completing this unit, you will be able to:
 Define paranoia and delusional disorders;
 Enlist various types of paranoia delusional disorders;
 Elucidate the Symptoms and causes of the disorders;
 Explain the Interventional approaches for the delusional disorders; and
 Analyse the prognosis.

2.2 CONCEPT OF PARANOIA

2.2.1 Definition of Paranoia
Here the patient becomes a prey to premature delusion. According to Kraeplein, in the
disease the cause of delusion is internal, and no hallucination is involved.
A paranoid disorder is a medical illness, which happens to affect the brain, and causes
changes in thinking and feeling. It’s nobody’s fault when it develops, and certainly does
not mean any personal weakness or failure. It’s an illness just as diabetes and asthma
are illnesses.
It’s not all that uncommon, either Paranoia disorder consists of pervasive, long-
standing suspiciousness and generalised mistrust of others. Those with the condition
are hypersensitive, are easily slighted, and habitually relate to the world by vigilant
scanning of the environment for clues or suggestions to validate their prejudicial ideas
or biases.
Paranoid individuals are eager observers. They think they are in danger and look for
signs and threats of that danger, disregarding any facts. They tend to be guarded and
suspicious and have quite constricted emotional lives. Their incapacity for meaningful
emotional involvement and the general pattern of isolated withdrawal often lend a quality
of schizoid isolation to their life experience.
Despite the pervasive suspicions they have of others, patients are not delusional (except
in rare, brief instances brought on by stress ). Most of the time, they are in touch with
reality, except for their misinterpretation of others’ motives and intentions.
Paranoid Personality Disorder patients are not psychotic but their conviction that others
are trying to “get them” or humiliate them in some way often leads to hostility and social
22 isolation.
The word paranoia comes from the Greek word indicating madness and the term Paranoid and Delusional
Disorder
was used to describe a mental illness in which a delusional belief is the sole or most
prominent feature. In original attempt at classifying different forms of mental illness,
Kraepelin used the term pure paranoia to describe a condition where a delusion was
present, but without any apparent deterioration in intellectual abilities and without any
of the other features of dementia praecox, the condition later renamed “schizophrenia”.
Notably, in his definition, the belief does not have to be persecutory to be classified as
paranoid, so any number of delusional beliefs can be classified as paranoia. For example,
a person who has the sole delusional belief that he is an important religious figure would
be classified by Kraepelin as having pure paranoia.
Even at the present time, a delusion need not be suspicious or fearful to be classified as
paranoid. A person might be diagnosed as a paranoid schizophrenic without delusions
of persecution, simply because their delusions refer mainly to themselves.

2.2.2 Characteristic Features of Paranoia

People with this disorder do not trust other people. In fact, the central characteristic of
people is a high degree of mistrustfulness and suspicion when interacting with others.
Even friendly gestures are often interpreted as being manipulative or malevolent.
Whether the patterns of distrust and suspicion begin in childhood or in early adulthood,
they quickly come to dominate the lives of those suffering from the said disorder. Such
people are unable or afraid to form close relationships with others. They suspect
strangers, and even people they know, of planning to harm or exploit them when there
is no good evidence to support this belief. As a result of their constant concern about
the lack of trustworthiness of others, patients with this disorder do not have intimate
friends or close human contacts. They do not fit in and they do not make good “team
players.”
Interactions with others are characterised by wariness and not infrequently by hostility.
If they marry or become otherwise attached to someone, the relationship is often
characterised by pathological jealousy and attempts to control their partner. They often
assume their sexual partner is “cheating” on them. People suffering from this disorder
are very difficult to deal with. They never seem to let down their defenses. They are
always looking for and finding evidence that others are against them.
Their fear, and the threats they perceive in the innocent statements and actions of others,
often contributes to frequent complaining or unfriendly withdrawal or aloofness. They
can be confrontational, aggressive and disputatious. It is not unusual for them to sue
people they feel have wronged them. In addition, patients with this disorder are known
for their tendency to become violent. Individual counseling seems to work best but it
requires a great deal of patience and skill on the part of the therapist. Phelan, M.
Padraig, W. Stern, J (2000) paranoia and paraphrenia are debated entities that were
detached from dementia praecox by Kraepelin, who explained paranoia as a continuous
systematized delusion arising much later in life with no presence of either hallucinations
or a deteriorating course, paraphrenia as an identical syndrome to paranoia but with
hallucinations.

2.2.3 Symptoms of Paranoia

The main symptom is permanent delusion. It should be kept in mind that there is delusion
in schizophrenia also but in that case it is not permanent or organised. In paranoia the
symptoms of delusion appear gradually, and the patient is sentimental, suspicious, irritable,
23
Schizophrenia and Other introverted, depressed, obstinate, jealous, selfish, unsocial and bitter. Hence his social
Psychotic Disorders
and family adjustment is not desirable, and while he has the highest desirable, the effort
that he is prepared to expend is correspondingly little. Here the person does not
acknowledge his own failures or faults, and by sometimes accepting certain qualities as
belonging to himself, even when imaginary, he develops paranoia.
The “Diagnostic and Statistical Manual of Mental Disorders”, fourth edition (DSM-
IV), the US manual of the mental health professional; lists the following symptoms for
paranoid personality disorder:
 Preoccupied with unsupported doubts about friends or associates.
 Suspicious; unfounded suspicions; believes others are plotting against him/her.
 Perceives attacks on his/her reputation that are not clear to others, and is quick to
counterattack.
 Maintains unfounded suspicions regarding the fidelity of a spouse or significant
other.
 Reads negative meanings into innocuous remarks.
 Reluctant to confide in others due to a fear that information may be used against
him/her.
 Self-referential thinking:Sensing that other people in the world are always talking
about the paranoid individual.
 Thought broadcasting: The sense that other people can read the paranoid
individual’s mind.
 Magical thinking: The sense that the paranoid individual can use his or her thoughts
to influence other people’s thoughts and actions.
 Thought withdrawal: The sense that people are stealing the paranoid individual’s
thoughts.
 Thought insertion: The sense that people are putting thoughts into the paranoid
individual’s mind.
 Ideas of reference: The sense that the television and/or radio are specifically
addressing the paranoid individual.

2.2.4 Kinds of Paranoia

Persecutory paranoia : This is the most prevalent type of paranoia, and in this patient
makes himself believe that all those around him are his enemies, bent on harming him or
even taking his life. In this delusion people of an aggressive temperament often turns
dangerous killers.
Religious paranoia : Here the patients suffer from a permanent delusion of a primarily
religious nature. He for example believes, that he is the messenger of God who has
been sent to the world to propagate some religion.
Reformatory paranoia : In this the patient turns to considering himself a great reformer.
He accordingly looks upon all those around him. As suffering from dangerous disease,
and believes that he is their reformer and curator.
Erotic paranoia : Here the patient often tends to believe that some members of the
family of the opposite sex, belonging to an illustrious family, want to marry him. Such
people even write love letters and there by, cause much botheration to other people.
24
Litigious paranoia : In this kind the patient takes to feeling meaningless cases against Paranoid and Delusional
Disorder
other people and feels that people are linked together to bother him. Sometimes he,
even tries to murder.
Hypochondrical paranoia : In this kind the patients believes that he is suffering from
all kind of ridiculous diseases, and also that some other people are to blame for his
suffering.
Self Assessment Qeustions
1) Define Paranoia and bring out the characteristic features of this disorder.
.....................................................................................................................
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.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) What are the symptoms of paranoia?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) What are the different kinds of paranoia?
.....................................................................................................................
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2.3 CAUSES OF PARANOIA

2.3.1 Homosexual Fixation
According to Freud, the patient suffering from the disease has repressed his tendency
to homosexual love to such an extent that he develops a fixation concerning it. Freud’s
view has been found correct in many cases, but it does not explain each and every case
of the disease.

2.3.2 Feelings of Inferiority

Here the psychologists have found that the main cause of paranoia is a sense of inferiority
that may be caused by a variety of condition such as failure, disgust, sense of guilt.

25
Schizophrenia and Other 2.3.3 Emotional Complex
Psychotic Disorders

Certain psychologist points out emotional complexes, and also believe that they are
seen to be present in other mental diseases as also in normal individuals.

2.3.4 Personality Type

Cameron believes a certain type to be more susceptible to this disease, a personality
that has sentimentally, jealousy, suspicion, ambition, selfishness and shyness etc. Patients
of paranoia do exhibit these peculiarities of personality but on this basis they cannot be
said to belong to definite personality.

2.3.5 Heredity
In the opinion of Fisher the main responsibility of paranoia lies fairly and squarely upon
heredity, although he does not deny the importance of repression and emotional
complexes.

The causes of paranoia are not physical because no patient exhibits any signs of physical
deformity and among the causes there are many important” ones, such as defects of
personality, sense of inferiority, repression etc.

2.3.6 Biological
Researchers are studying how abnormalities of certain areas of the brain might be involved
in the development of delusional disorders. An imbalance of certain chemicals in the
brain, called neurotransmitters, also has been linked to the formation of delusional
symptoms. Neurotransmitters are substances that help nerve cells in the brain send
messages to each other. An imbalance in these chemicals can interfere with the
transmission of messages, leading to symptoms.

2.3.7 Environmental/Psychological
Evidence suggests that delusional disorder can be triggered by stress. Alcohol and drug
abuse also might contribute to the condition. People who tend to be isolated, such as
immigrants or those with poor sight and hearing, appear to be more vulnerable to
developing delusional disorder.

2.3.8 Dysfunctional Cognitive Processing

An elaborate term for thinking is “cognitive processing.” Delusions may arise from
distorted ways people have of explaining life to themselves. The most prominent cognitive
problems involve the manner in which delusion sufferers develop conclusions both about
other people, and about causation of unusual perceptions or negative events.

Studies examining how people with delusions develop theories about reality show that
the subjects have ideas which which they tend to reach an inference based on less
information than most people use.

This “jumping to conclusions” bias can lead to delusional interpretations of ordinary

events. For example, developing flu-like symptoms coinciding with the week new
neighbours move in might lead to the conclusion, “the new neighbours are poisoning
me.”
26
The conclusion is drawn without considering alternative explanations—catching an illness Paranoid and Delusional
Disorder
from a relative with the flu, that a virus seems to be going around at work, or that the
tuna salad from lunch at the deli may have been spoiled.
Additional research shows that persons prone to delusions “read” people differently
than non-delusional individuals do. Whether they do so more accurately or particularly
poorly is a matter of controversy.
Delusional persons develop interpretations about how others view them that are distorted.
They tend to view life as a continuing series of threatening events. When these two
aspects of thought co-occur, a tendency to develop delusions about others wishing to
do them harm is likely.

2.3.9 Medical Causes

Many medical conditions can lead to paranoid thoughts. Alzheimer’s disease, chemical
deficiencies, cathinone poisoning and neurological degeneration disorders can harm the
nervous system and lead to confusion and unstable emotions. Sufferers of these conditions
sometimes forget who they can trust and also lose the ability to differentiate between
trustworthy and suspicious behaviour.

2.3.10 Associated Mental Illnesses

Some mental illnesses are associated with paranoia. An inability to think clearly can
cause an individual to lose the ability to differentiate between trustworthy and not
trustworthy individuals. Schizophrenia causes an individual to have bizarre or disorganised
thoughts. Some individuals hallucinate and begin to believe that which they hallucinate
rather than their friends and family members. Psychosis involves a detachment from
reality that can lead to paranoid thoughts.

2.3.11 Substance Abuse

Many substances lead to paranoia if abused: alcohol, amphetamines, crack, crystal
meth, cocaine, ecstasy, marijuana, narcotics, opioids, opium, pain killers, oxycodone,
sleeping pills and tranquilizers. Withdrawal from many of these substances can also
trigger paranoid thoughts, so withdrawal must be handled carefully with close supervision.
Self Assessment Questions
1) What are the causes of paranoia?
.....................................................................................................................
.....................................................................................................................
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.....................................................................................................................
2) Discuss feelings of inferiority and emotional complex as causes of paranoia.
.....................................................................................................................
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27
Schizophrenia and Other
Psychotic Disorders 3) Delineate the hereditary factors and biological factors as causes of paranoia.
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4) What is dysfunctional cognitive processing?
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5) What are the medical causes and associated mental illnesses as causes of
paranoia?
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2.4 DELUSIONAL DISORDER

Delusions are irrational beliefs, held with a high level of conviction, that are highly resistant
to change even when the delusional person is exposed to forms of proof that contradict
the belief.
Non-bizarre delusions are considered to be plausible; that is, there is a possibility that
what the person believes to be true could actually occur a small proportion of the time.
Conversely, bizarre delusions focus on matters that would be impossible in reality. For
example, a non-bizarre delusion might be the belief that one’s activities are constantly
under observation by federal law enforcement or intelligence agencies, which actually
does occur for a small number of people.
By contrast, a man who believes he is pregnant with German Shepherd puppies holds
a belief that could never come to pass in reality. Also, for beliefs to be considered
delusional, the content or themes of the beliefs must be uncommon in the person’s
culture or religion. Generally, in delusional disorder, these mistaken beliefs are organised
into a consistent world-view that is logical other than being based on an improbable
foundation.

2.4.1 Characteristic Features

Unlike most other psychotic disorders, the person with delusional disorder typically
does not appear obviously odd, strange or peculiar during periods of active illness. Yet
the person might make unusual choices in day-to-day life because of the delusional
beliefs. Expanding on the previous example, people who believe they are under
government observation might seem typical in most ways but could refuse to have a
28
telephone or use credit cards in order to make it harder for “those Federal agents” to Paranoid and Delusional
Disorder
monitor purchases and conversations.
Most mental health professionals would concur that until the person with delusional
disorder discusses the areas of life affected by the delusions, it would be difficult to
distinguish the sufferer from members of the general public who are not psychiatrically
disturbed. Another distinction of delusional disorder compared with other psychotic
disorders is that hallucinations are either absent or occur infrequently.
The person with delusional disorder may or may not come to the attention of mental
health providers. Typically, while delusional disorder sufferers may be distressed about
the delusional “reality,” they may not have the insight to see that anything is wrong with
the way they are thinking or functioning. Regarding the earlier example, those suffering
delusion might state that the only thing wrong or upsetting in their lives is that the
government is spying, and if the surveillance would cease, so would the problems.
Similarly, the people suffering the disorder attribute any obstacles or problems in
functioning to the delusional reality, separating it from their internal control. Furthermore,
whether unable to get a good job or maintain a romantic relationship, the difficulties
would be blamed on “government interference” rather than on their own failures or
omissions.
Unless the form of the delusions causes illegal behaviour, somehow affects an ability to
work, or otherwise deal with daily activities, the delusional disorder sufferer may adapt
well enough to navigate life without coming to clinical attention. When people with
delusional disorder decide to seek mental health care, the motivation for getting treatment
is usually to decrease the negative emotions of depression, fearfulness, rage, or constant
worry caused by living under the cloud of delusional beliefs, not to change the unusual
thoughts themselves.
Delusional disorder, previously called paranoid disorder, is a type of serious mental
illness called a “psychosis” in which a person cannot tell what is real from what is
imagined. The main feature of this disorder is the presence of delusions, which are
unshakable beliefs in something untrue.
People with delusional disorder experience non-bizarre delusions, which involve
situations that could occur in real life, such as being followed, poisoned, deceived,
conspired against, or loved from a distance. These delusions usually involve the
misinterpretation of perceptions or experiences. In reality, however, the situations are
either not true at all or highly exaggerated.
People with delusional disorder often can continue to socialise and function normally,
apart from the subject of their delusion, and generally do not behave in an obviously
odd or bizarre manner. This is unlike people with other psychotic disorders, who also
might have delusions as a symptom of their disorder. In some cases, however, people
with delusional disorder might become so preoccupied with their delusions that their
lives are disrupted.
Psychiatrists make a distinction between the milder paranoid personality disorder
described above and the more debilitating delusional (paranoid) disorder. The hallmark
of this disorder is the presence of a persistent, nonbizarre delusion without symptoms
of any other mental disorder.
Delusions are firmly held beliefs that are untrue, not shared by others in the culture, and
not easily modifiable. Five delusional themes are frequently seen in delusional disorder.
In some individuals, more than one of them is present. 29
Schizophrenia and Other Whether or not persons with delusional disorder are dangerous to others has not been
Psychotic Disorders
systematically investigated, but clinical experience suggests that such persons are rarely
homicidal. Delusional patients are commonly angry people, and thus they are perceived
as threatening. In the rare instances when individuals with delusional disorder do become
violent, their victims are usually people who unwittingly fit into their delusional scheme.
The person in most danger from an individual with delusional disorder is a spouse or
lover.

2.4.2 Types of Delusional Disorder

Paranoia is an unfounded or exaggerated distrust of others, sometimes reaching delusional
proportions. Paranoid individuals constantly suspect the motives of those around them,
and believe that certain individuals, or people in general, are “out to get them.”
Paranoid perceptions and behaviour may appear as features of a number of mental
illnesses, including depression and dementia, but are most prominent in three types of
psychological disorders: paranoid schizophrenia, delusional disorder (persecutory type),
and paranoid personality disorder (PPD).
Individuals with paranoid schizophrenia and persecutory delusional disorder experience
what is known as persecutory delusions: an irrational, yet unshakable, belief that someone
is plotting against them. Persecutory delusions in paranoid schizophrenia are bizarre,
sometimes grandiose, and often accompanied by auditory hallucinations. Individuals
with delusional disorder may seem offbeat or quirky rather than mentally ill, and, as
such, may never seek treatment.
Persons with paranoid personality disorder (PPD) tend to be self-centered, self-
important, defensive, and emotionally distant. Their paranoia manifests itself in constant
suspicions rather than full-blown delusions. The disorder often impedes social and
personal relationships and career advancement. Some individuals with PPD are described
as “litigious,” as they are constantly initiating frivolous law suits. PPD is more common
in men than in women, and typically begins in early adulthood.
The exact cause of paranoia is unknown. Potential causal factors may be genetics,
neurological abnormalities, changes in brain chemistry, and stress. Paranoia is also a
possible side effect of drug use and abuse (for example, alcohol, marijuana,
amphetamines, cocaine, PCP). Acute, or short term, paranoia may occur in some
individuals overwhelmed by stress.
The diagnosis of patients with paranoid symptoms includes a thorough physical
examination and patient history to rule out possible organic causes (such asdementia)
or environmental causes (such as extreme stress). If a psychological cause is suspected,
a psychologist will conduct an interview with the patient and may administer one of
several tests to evaluate mental status.
Paranoia that is symptomatic of paranoid schizophrenia, delusional disorder,or paranoid
personality disorder should be treated by a psychologist and/or psychiatrist.
Antipsychotic medication such as thioridazine (Mellaril),haloperidol (Haldol),
chlorpromazine (Thorazine), clozapine (Clozaril), or risperidone (Risperdal) may be
prescribed, and cognitive therapy or psychotherapy may be employed to help the patient
cope with their paranoia and/or persecutory delusions. It is uncertain whether
antipsychotic medication benefit individuals with paranoid personality disorder and may
even pose long-term risks.
If an underlying condition, such as depression or drug abuse, is found to be triggering
the paranoia, an appropriate course of medication and/or psychosocial therapy is
30 employed to treat the primary disorder.
Because of the inherent mistrust felt by paranoid individuals, they often must be coerced Paranoid and Delusional
Disorder
into entering treatment. As unwilling participants, their recovery may be hampered by
efforts to sabotage treatment (for example, not taking medication or not being forthcoming
with a therapist). They may also exhibit a lack of insight into their condition or the belief
that the therapist is plotting against them. Although their lifestyles may be restricted,
some patients with PPD or persecutory delusional disorder continue to function in society
without treatment.
Distrust is the hallmark of delusional disorder. Someone who suffers from this disorder
is very defensive, sometimes to the point of being aggressive, and may constantly question
the motives of others. Even if people appear harmless on the surface, the patient believes
that they are simply trying to lull the patient into a sense of complacency, and the patient
will remain on guard as a result. Other symptoms of delusional disorder can include a
sense of social isolation caused in part by the patient’s defensive and suspicious
behaviour, and a lack of humor.

2.4.3 Delusion of Grandeur

In this patient believes himself to be, a great individual, and according to Bleuler, this
delusion of grandeur accompanies a persecutory delusion. A delusion is (common in
paranoia) that you are much greater and more powerful and influential than you really
are.
One of the toughest psychiatric anomalies both to diagnose and treat is delusion disorder
like delusion of grandeur, delusional paranoid, even delusional jealousy. The reason
why diagnosis can be tough is the person is often working quite typically in the world.
The delusions in this disorder are non bizarre, meaning that they can essentially be
plausible even if they are not true. Those suffering from this disorder often will not
believe they have a problem, so it is difficult to get them into treatment.
While paranoia is the most typical manifestation, there are more types of delusion disorder
including delusion of grandeur, delusional paranoid, even delusional jealousy as well as
for example, believing one is the secret love interest of a famous person, being convinced
one has striking abilities or is very significant, worrying about physical problems or
disfigurements that do not exist, or believing that one’s romantic partner is unfaithful.
Psychological fitness treatment is sometimes refused because of these convictions, which
are immune to any sort of disproof. The patient is certain they are correct.
Therapists who are ready to be used slightly different treatments, instead adopt the
more usual drugs or characteristic psychotherapy approaches. They may gain the
patient’s trust enough to begin exploring any doubts the person expresses about their
own ideology. The two of them can work in partnership, gradually discovering real
world explanations for those ideology. If the therapist treads conscientiously and uses
tactfully, then the patient and therapist together can work through the delusion disorder
like delusion of grandeur, delusional paranoid, even delusional jealousy and effect a
cure.

2.4.4 Motivated or Defensive Delusions

Some predisposed persons might suffer the onset of an ongoing delusional disorder
when coping with life and maintaining high self esteem becomes a significant challenge.
In order to preserve a positive view of oneself, a person views others as the cause of
personal difficulties that may occur. This can then become an ingrained pattern of thought.

31
Schizophrenia and Other
Psychotic Disorders 2.5 DELUSIONS AND OTHER DISORDERS
Even though the main characteristic of delusional disorder is a noticeable system of
delusional beliefs, delusions may occur in the course of a large number of other psychiatric
disorders.
Delusions are often observed in persons with other psychotic disorders such as
schizophrenia and schizoaffective disorder. In addition to occurring in the psychotic
disorders, delusions also may be evident as part of a response to physical, medical
conditions (such as brain injury or brain tumors), or reactions to ingestion of a drug.
Delusions also occur in the dementias, which are syndromes wherein psychiatric
symptoms and memory loss result from deterioration of brain tissue. Because delusions
can be shown as part of many illnesses, the diagnosis of delusional disorder is partially
conducted by process of elimination.
If the delusions are not accompanied by persistent, recurring hallucinations, then
schizophrenia and schizoaffective disorder are not appropriate diagnoses. If the delusions
are not accompanied by memory loss, then dementia is ruled out.
If there is no physical illness or injury or other active biological cause (such as drug
ingestion or drug withdrawal), then the delusions cannot be attributed to a general
medical problem or drug-related causes. If delusions are the most obvious and pervasive
symptom, without hallucinations, medical causation, drug influences or memory loss,
then delusional disorder is the most appropriate categorisation.
Because delusions occur in many different disorders, some clinician researchers have
argued that there is little usefulness in focusing on what diagnosis the person has been
given.
Those who ascribe to this view believe it is more important to focus on the symptom of
delusional thinking, and find ways to have an effect on delusions, whether they occur in
delusional disorder or schizophrenia or schizoaffective disorder.
The majority of psychotherapy techniques used in delusional disorder come from
symptom-focused (as opposed to diagnosis-focused) researcher-practitioners.
Self Assessment Questions
1) What is Delusional Disorder? Define and bring out its characteristic features.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) What are delusions of grandeur?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
32
 Paranoid and Delusional
3) Describe delusions of persecution and erotomania. Disorder

.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
4) What are motivated defensive delusions?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
5) Discuss delusions as part of other psychiatric disorders.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

2.6 TREATMENT APPROACHES TO PARANOIA

AND DELUSIONAL DISORDER
A cure of paranoia is very difficult and it is essential that treatment should be started
immediately the disease comes to be known. Once it grows on a person there is no
curing to it. The chief method of curing it is the following:

2.6.1 Treatment and Cure

A cure of paranoia is very difficult and it is essential that treatment should be started
immediately the disease comes to be known. Once it grows on a person there is no
curing to it. The chief method of curing it is the administering Injection of Insulin. Some
patients also responds to this treatment but this cannot be said of all.

2.6.2 Psychoanalytic Method

Compared to other mental diseases, this disease does not respond immediately to
psychoanalytic treatment because, being suspicious, the patient does not cooperate
with the doctor. Even then, with due precaution, certain results can be achieved by
employing this method.

2.6.3 Cognitive Behavioural Therapy (CBT)

CBT or other forms of psychotherapy may be helpful for certain people who have
paranoia. CBT attempts to make a person more aware of his or her actions and
motivations, and tries to help the individual learn to more accurately interpret cues
around him or her, in an effort to help the individual change dysfunctional behaviours.
Difficulty can enter into a therapeutic relationship with a paranoid individual, due to the
level of mistrust and suspicion that is likely to interfere with their ability to participate in
this form of treatment. 33
Schizophrenia and Other Support groups can be helpful for some paranoid individuals—particularly helpful in
Psychotic Disorders
assisting family members and friends who must learn to live with, and care for paranoid
individuals.

2.6.4 Drug Therapy

Treatment with appropriate antipsychotic drugs may help the paranoid patient overcome
some symptoms. Although the patient’s functioning may be improved, the paranoid
symptoms often remain intact. Some studies indicate that symptoms improve following
drug treatment, but the same results sometimes occur among patients who receive a
placebo, a “sugar pill” without active ingredients. This finding suggests that in some
cases the paranoia diminishes for psychological reasons rather than because of the
drug’s action.
Delusional disorder treatment often involves atypical (also called novel or newer-
generation ) antipsychotic medications, which can be effective in some patients.
Risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa) are all
examples of atypical or novel antipsychotic medications.
If agitation occurs, a number of different antipsychotics can be used to conclude the
outbreak of acute agitation. Agitation, a state of frantic activity experienced concurrently
with anger or exaggerated fearfulness, increases the risk that the client will endanger
self or others.
To decrease anxiety and slow behaviour in emergency situations where agitation is a
factor, an injection of haloperidol (Haldol) is often given usually in combination with
other medications (often lorazepam , also known as Ativan).
Agitation in delusional disorder is a typical response to severe or harsh confrontation
when dealing with the existence of the delusions. It can also be a result of blocking the
individual from performing inappropriate actions the client views as urgent in light of the
delusional reality.
A novel antipsychotic is generally given orally on a daily basis for ongoing treatment
meant for long-term effect on the symptoms.
Response to antipsychotics in delusional disorder seems to follow the “rule of thirds,” in
which about one-third of patients respond somewhat positively, one-third show little
change, and one-third worsen or are unable to comply.
Cognitive therapy has shown promise as an emerging treatment for delusions. The
cognitive therapist tries to capitalise on any doubt the individual has about the delusions;
then attempts to develop a joint effort with the sufferer to generate alternative
explanations, assisting the client in checking the evidence. This examination proceeds in
favour of the various explanations.
Much of the work is done by use of empathy, asking hypothetical questions in a form of
therapeutic Socratic dialogue—a process that follows a basic question and answer
format, figuring out what is known and unknown before reaching a logical conclusion.

2.6.5 Combining Pharmacotherapy with Cognitive Therapy

The integration of both the treatment may being out the possible underlying biological
problems and the symptoms can be reduced with psychotherapy.

2.6.6 Psychotherapy
This is the primary treatment for delusional disorder, including psychosocial treatment
which can help with the behavioural and psychological problems associated with
34
delusional disorder. Through therapy, patients also can learn to control their symptoms,
identify early warning signs of relapse, and develop a relapse prevention plan. Paranoid and Delusional
Disorder
Psychosocial therapies include the following:
Individual psychotherapy: Can help the person recognise and correct the underlying
thinking that has become distorted.
Cognitive behavioural therapy (CBT): Can help the person learn to recognise and
change thought patterns and behaviours that lead to troublesome feelings.
Family therapy: Can help families deal more effectively with a loved one who has
delusional disorder, enabling them to contribute to a better outcome for the person.

2.6.7 Prognosis of Paranoia and Delusional Disorder

Predicting the prognosis of an individual suffering from Paranoia is quite difficult. Paranoia
generally becomes a whole life or lifelong condition if there exists any underlying mental
disorder, such as schizophrenia or paranoid personality disorder. It certainly and
sometimes get better with some treatments or remission or with slight changes in
medication. People who have symptoms of paranoia as part of another medical condition
may also have a waxing and waning mental course.
Sometimes it is the case that paranoia is caused by the use of a particular drug or
medication. In this case, it is possible that discontinuing that substance may completely
reverse the symptoms of paranoia.
Paranoia can also occur as a symptom of other neurological diseases. Individuals suffering
from the aftereffects of strokes, brain injuries, various types of dementia (including
Alzheimer’s disease ), Huntington’s disease, and Parkinson’s disease may manifest
paranoia as part of their symptom complex. The paranoia may decrease in intensity
when the underlying disease is effectively treated, although since many of these diseases
are progressive, the paranoia may worsen over time along with the progression of the
disease’s other symptoms.

2.7 LET US SUM UP

We defined paranoia as a medical illness, which happens to affect the brain, and causes
changes in thinking and feeling. Those with the condition are hypersensitive, are easily
slighted, and habitually relate to the world by vigilant scanning of the environment for
clues or suggestions to validate their prejudicial ideas or biases.
Paranoid individuals are eager observers. They think they are in danger and look for
signs and threats of that danger, disregarding any facts. They tend to be guarded and
suspicious and have quite constricted emotional lives. Their incapacity for meaningful
emotional involvement and the general pattern of isolated withdrawal often lend a quality
of schizoid isolation to their life experience.
Even at the present time, a delusion need not be suspicious or fearful to be classified as
paranoid. A person might be diagnosed as a paranoid schizophrenic without delusions
of persecution, simply because their delusions refer mainly to themselves.
Their fear, and the threats they perceive in the innocent statements and actions of others,
often contributes to frequent complaining or unfriendly withdrawal or aloofness. They
can be confrontational, aggressive and disputatious. It is not unusual for them to sue
people they feel have wronged them. The main symptom of paranoia is permanent
delusion. It should be kept in mind that there is delusion in schizophrenia also but in that
case it is not permanent or organised. In paranoia the symptoms of delusion appear
gradually, and the patient is sentimental, suspicious, irritable, introverted, depressed, 35
Schizophrenia and Other obstinate, jealous, selfish, unsocial and bitter. Hence his social and family adjustment is
Psychotic Disorders
not desirable, and while he has the highest desirable, the effort that he is prepared to
expend is correspondingly little.
The “Diagnostic and Statistical Manual of Mental Disorders”, fourth edition (DSM-
IV), has listed the symptoms of paranoid personality disorder:
Then we deal with different kinds of paranoia such as the persecutory, religious,
reformatory, erotic, litigious etc. Then the causes of paranoia were delineated.
Delusions are often observed in persons with other psychotic disorders such as
schizophrenia and schizoaffective disorder. In addition to occurring in the psychotic
disorders, delusions also may be evident as part of a response to physical, medical
conditions (such as brain injury or brain tumors), or reactions to ingestion of a drug.
Delusions also occur in the dementias, which are syndromes wherein psychiatric
symptoms and memory loss result from deterioration of brain tissue. Because delusions
can be shown as part of many illnesses, the diagnosis of delusional disorder is partially
conducted by process of elimination.
The majority of psychotherapy techniques used in delusional disorder come from
symptom-focused (as opposed to diagnosis-focused) researcher-practitioners. A cure
of paranoia is very difficult and it is essential that treatment should be started immediately
the disease comes to be known. Once it grows on a person there is no curing to it. The
chief method of curing it is the following:
Compared to other mental diseases, this disease does not respond immediately to
psychoanalytic treatment because, being suspicious, the patient does not cooperate
with the doctor. Even then, with due precaution, certain results can be achieved by
employing this method.
CBT or other forms of psychotherapy may be helpful for certain people who have
paranoia. CBT attempts to make a person more aware of his or her actions and
motivations, and tries to help the individual learn to more accurately interpret cues
around him or her, in an effort to help the individual change dysfunctional behaviours.
Difficulty can enter into a therapeutic relationship with a paranoid individual, due to the
level of mistrust and suspicion that is likely to interfere with their ability to participate in
this form of treatment.
Delusional disorder treatment often involves atypical (also called novel or newer-
generation ) antipsychotic medications, which can be effective in some patients.
Risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa) are all
examples of atypical or novel antipsychotic medications.
Predicting the prognosis of an individual suffering from Paranoia is quite difficult. Paranoia
generally becomes a whole life or lifelong condition if there exists any underlying mental
disorder, such as schizophrenia or paranoid personality disorder. It certainly and
sometimes get better with some treatments or remission or with slight changes in
medication. People who have symptoms of paranoia as part of another medical condition
may also have a waxing and waning mental course.

2.8 UNIT END QUESTIONS

1) Define paranoia and delineate its characteristic features.
2) What are the symptoms of paranoi and what are its causes?
3) What are delusional disorders?
36 4) Describe in detail the delusional disorder of grandeur and persecution
5) What are motivated delusions? Paranoid and Delusional
Disorder
6) What are the various treatment methods available for paranoia and delusional
disorders? How effective they are?

2.9 SUGGESTED READINGS

Farrell, John (2006). Paranoia and Modernity: Cervantes to Rousseau. Cornell
University Press.
Freeman, D. & Garety, P. A. (2004). Paranoia: The Psychology of Persecutory
Delusions. Hove: Psychology Press.
Igmade (Stephan Trüby et al., eds.), 5 Codes: Architecture, Paranoia and Risk in
Times of Terror, Birkhäuser 2006.
Kantor, Martin (2004). Understanding Paranoia: A Guide for Professionals,
Families, and Sufferers. Westport: Praeger Press.
Mezzich JE, Honda Y, Kastrup MC, eds. Psychiatric Diagnosis: A World
Perspective. New York, NY: Springer Verlag; 1994.
Sims, A. (2002). Symptoms in the mind: An Introduction to Descriptive
Psychopathology (3rd edition). Edinburgh
References
Moore DP, Jefferson JW. Paranoid personality disorder. In: Moore DP, Jefferson JW,
eds. Handbook of Medical Psychiatry. 2nd ed. Philadelphia, Pa: Mosby Elsevier; 2004:
chap 134.
Satterfield JM, Feldman MD. Paranoid personality disorder. In: Ferri FF, ed. Ferri’s
Clinical Advisor 2008: Instant Diagnosis and Treatment. 1st ed. Philadelphia, Pa: Mosby
Elsevier; 2008.
Sims, A. (1995) Symptoms in the mind: An introduction to descriptive psychopathology.
Edinburgh: Elsevier Science Ltd.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental
Disorders, (4th ed., text revision). Washington, DC: American Psychiatric Association.
Valdimarsdottir U, Hultman CM, Harlow B, Cnattingius S, Sparen P. Psychotic illness
in first-time mothers with no previous psychiatric hospitalisations: a population-based
study. PLoS Med. Feb 10 2009;6(2):e13.
Jorgensen P, Bennedsen B, Christensen J, Hyllested A. Acute and transient psychotic
disorder: co morbidity wit h personality diso rder. Acta Psychiatr
Scand. Dec 1996;94(6):460-4.
Karagianis JL, Dawe IC, Thakur A, et al. Rapid tranquilization with olanzapine in acute
psychosis: a case series. J Clin Psychiatry. 2001;62 Suppl 2:12-6.
Brook S, Lucey JV, Gunn KP. Intramuscular ziprasidone compared with intramuscular
haloperidol in the treatment of acute psychosis. Ziprasidone I.M. Study Group. J Clin
Psychiatry. Dec 2000;61(12):933-41.
Correll CU, Smith CW, Auther AM, McLaughlin D, Shah M, Foley C, et al. Predictors
of remission, schizophrenia, and bipolar disorder in adolescents with brief psychotic
disorder or psychotic disorder not otherwise specified considered at very high risk for
schizophrenia. J Child Adolesc Psychopharmacol. Oct 2008;18(5):475-90.
37
Schizophrenia and Other Beighley PS, Brown GR, Thompson JW Jr. DSM-III-R brief reactive psychosis among
Psychotic Disorders
Air Force recruits. J Clin Psychiatry. Aug 1992;53(8):283-8. [Medline].
Jablensky A, Sartorius N, Ernberg G, et al. Schizophrenia: manifestations, incidence
and course in different cultures. A World Health Organisation ten-country study. Psychol
Med Monogr Suppl. 1992;20:1-97. [Medline].
Jauch DA, Carpenter WT Jr. Reactive psychosis. I. Does the pre-DSM-III concept
define a third psychosis?. J Nerv Ment Dis. Feb 1988;176(2):72-81.
Jauch DA, Carpenter WT Jr. Reactive psychosis. II. Does DSM-III-R define a third
psychosis?. J Nerv Ment Dis. Feb 1988;176(2):82-6.
Johnson FA. African perspective on mental disorder. In: Mezzich JE, Honda Y, Kastrup
MC, eds. Psychiatric Diagnosis: A World Perspective. New York, NY: Springer
Verlag; 1994.
Jorge MR, Mezzich JE. Latin American contributions to psychiatric nosology and
classification. In: Mezzich JE, Honda Y, Kastrup MC, eds. Psychiatric Diagnosis: A
World Perspective. New York, NY: Springer Verlag; 1994.
Jorgensen P, Jensen J. An attempt to operationalise reactive delusional psychosis. Acta
Psychiatr Scand. Nov 1988;78(5):627-31.
Karno M, Jenkins JH. Cultural considerations in the diagnosis of schizophrenia and
related disorders and psychotic disorders not otherwise classified. In: TA Widiger,
ed. DSM-IV Source Book. Washington DC: American Psychiatric Press; 1994.
Lin KM. Cultural influences on the diagnosis of psychotic and organic disorders. In:
Mezzich JE, Kleinman A, Horacio F, Parron DL, eds. Culture and Psychiatric
Diagnosis: A DSM-IV Perspective. Washington DC: American Psychiatric
Press; 1996.
Mezzich JE, Lin KM. Acute and transient psychotic disorders and culture-bound
syndromes. In: Sadock BJ, Sadock VA, eds. Kaplan and Sadock’s Comprehensive
Textbook of Psychiatry. 6 th ed. Baltimore, Md: Lippincott Williams &
Wilkins; 1995:1049.
Pull CB, Chaillet G. The nosological views of French-speaking psychiatry. In: Mezzich
JE, Honda Y, Kastrup MC, eds. Psychiatric Diagnosis: A World Perspective. New
York, NY: Springer Verlag; 1994.

38
UNIT 3 PSYCHOTIC DISORDER DUE TO
GENERAL MEDICAL CONDITION
Structure
3.0 Introduction
3.1 Objectives
3.2 Medical Conditions that may Cause Psychosis
3.2.1 Neurologic Disorders that may Produce Psychiatric Symptoms

3.3 Symptoms of Psychotic Disorders

3.3.1 Types of Psychotic Disorders
3.3.2 Causes of Psychotic Disorders

3.4 Symptoms of Psychotic Disorders due to Medical Conditions

3.4.1 Symptoms
3.4.2 Types of Delusions
3.4.3 Hallucinations

3.5 Causes of Psychotic Disorders due to Medical Conditions

3.5.1 Functional Causes
3.5.2 General Medical Conditions
3.5.3 Psychoactive Drugs
3.5.4 A Stress Response
3.5.5 PostpartumPsychosis

3.6 Defense Mechanisms in Personality Disorders

3.6.1 Culturally Defined Disorder

3.7 Treatment
3.7.1 Early Intervention
3.7.2 Hospitalisation
3.7.3 Medications
3.7.4 Psychosocial Therapy

3.8 Let Us Sum Up

3.9 Unit End Questions
3.10 Suggested Readings and References

3.0 INTRODUCTION
This unit deals with psychotic disorders caused by medical conditions. We start with
explaining how these disorders caused by medical condition. Then we deal with the
psychotic disorders assiociated with neurological disorders. Then we present the various
features of psychotic disorders followed by symptoms of psychotic disorder. The
symptoms include delusions and hallucinations which are explained in detail. Then we
deal with the causes of psychological disorders due to medical conditions. Then we
deal with defense mechanisms and treatment approaches to the psychotic disorders
due to medical conditions.

39
Schizophrenia and Other
Psychotic Disorders 3.1 OBJECTIVES
On completing this unit, you will be able to:
 Describe the medical conditions that cause psychotic disorder;
 Elucidate the Neurologic disorder that may cause psychotic symptoms;
 Explain the symptoms of psychotic disorders;
 Delineate the Causes of psychotic disorders due to medical conditions;
 Explain stress syndrome and postpartum psychosis;
 Describe the Defense mechanisms in psychotic disorders;
 Analyse the psychotic disorder in terms of Culturally defined disorder; and
 Enlist the various Treatment approaches to medically induced psychotic disorder.

3.2 MEDICAL CONDITIONS THAT MAY CAUSE

PSYCHOSIS
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-
TR), the psychiatric presentation of a medical illness is classified as “the presence of
mental symptoms that are judged to be the direct physiological consequences of a
general medical condition.” Therefore, understanding common psychiatric symptoms
and the medical diseases that may cause or mimic them is of utmost importance. Failure
to identify these underlying causal medical conditions can be potentially dangerous
because serious and frequently reversible conditions can be overlooked. Proper diagnosis
of a psychiatric illness necessitates investigation of all appropriate medical causes of the
symptoms.
The following features suggest a medical origin to psychiatric symptoms:
 Late onset of initial presentation
 Known underlying medical condition
 A typical presentation of a specific psychiatric diagnosis
 Absence of personal and family history of psychiatric illnesses
 Illicit substance use
 Medication use
 Treatment resistance or unusual response to treatment
 Sudden onset of mental symptoms
 Abnormal vital signs
 Waxing and waning mental status.
Because multiple secondary causes of mental disorders exist, the major medical disorders
that can induce psychiatric symptoms are listed in the Table below

40
 Table: Medical Disorders that can Induce Psychiatric Symptoms* Psychotic Disorder Due to
General Medical
Medical and Toxic CNS Infectious Metabolic/ Cardiopulmo- Other Condition
Effects Endocrine nary
 Alcohol  Subdural  Pneumonia  Thyroid  Myocardial  Systemic lupus
 Cocaine hematoma  Urinary tract disorder infarction erythematosus
 Marijuana  Tumor infection  Adrenal  Congestive  Anemia
 Phencyclidine  Aneurysm  Sepsis disorder heart failure  Vasculitis
(PCP)  Severe  Malaria  Renal disorder  Hypoxia
 Lysergic acid hypertension  Legionnaire  Hepatic disorder  Hypercarbia
diethylamide  Meningitis disease  Wilson disease
(LSD)  Encephalitis  Syphilis  Hyperglycemia
 Heroin  Normal pressure  Typhoid  Hypoglycemia
 Amphetamines hydrocephalus  Diphtheria  Vitamin
 Jimson weed  Seizure disorder  HIV deficiency
 Gamma-  Multiple  Rheumatic  Electrolyte
hydroxybutyrate sclerosis fever imbalances
(GHB)  Herpes  Porphyria
 Benzodiazepines
 Prescription drugs

*(Adapted from Williams E, Shepherd S. Medical clearance of psychiatric patients. Emerg Med
Clin North Am. May 2000; 18:2; 193.)

3.2.1 Neurologic Disorders that may Produce Ssychiatrtic

Symptoms
Seizure disorder
Epilepsy is one of the most common chronic neurologic diseases, affecting approximately
1% of the US population. In India the prevalence is estimated to be 5.33 per 1000
population. Approximately 30-50% of patients with a seizure disorder have psychiatric
symptoms sometime during the course of their illness. Increased psychopathology has
been associated with different features (eg, seizure phenomenology, brain pathology,
antiepileptic drug use, psychosocial factors).
In partial seizures, psychiatric signs abound, with memory dysfunction, affective auras,
perceptual changes (e.g., hallucinations), and depersonalisation.
In temporal lobe epilepsy, the most common psychiatric abnormality is personality
change. Development of psychosis is also described in temporal lobe epilepsy.
Parkinson disease
Parkinson disease (PD) is a disorder characterised by movement abnormalities caused
by degeneration of the neurons in the substantia nigra. The prevalence of major
depression in patients with PD is estimated to be 40%, with prevalence rates of
4-70%. The anxiety syndromes in PD are apparently related to an underlying brain
disease, with evidence implicating noradrenergic dysfunction. In several studies, anxiety
syndromes developed before or after the onset of motor symptoms.
Brain tumors
Brain tumors and cerebrovascular disease are important causes of psychiatric symptoms
and patients with these diseases can present with virtually any symptom. A complete
clinical history and neurologic examination are essential in diagnosing either condition.
Given the nature of the onset and presentation of a cerebrovascular event, it is rarely
misdiagnosed as a mental disorder. However, up to 50% of patients with brain tumors
reportedly have manifestations of a psychiatric nature. 41
Schizophrenia and Other Frontal lobe tumors, which are responsible for approximately 88% of the patients with
Psychotic Disorders
psychiatric symptoms, can elicit presenting signs such as cognitive impairment, personality
change, or motor and language dysfunction.
Limbic and hypothalamic tumors can cause affective symptoms such as rage, mania,
emotional lability, and altered sexual behaviour. They can also produce delusions involving
complicated plots.
Hallucinations, which are often considered the hallmarks of psychiatric illness, can be
caused by focal neurologic pathology.
Multiple sclerosis
Multiple sclerosis (MS) is a demyelinating disorder characterised by multiple episodes
of symptoms of a neuropsychiatric nature related to multifocal lesions in the white matter
of the CNS.
Symptoms can be categorised as cognitive and psychiatric. Abstract reasoning, planning,
and organisational skills are some of the functions also affected by MS. Dementia may
eventually ensue.
Meningitis
Acute bacterial, fungal, and viral meningitis can be associated with a psychiatric
presentation with or without abnormal vital signs.
Patients usually present with acute confusion, headaches, memory impairments, and
fever with possible neck stiffness.
Parathyroid disorder
Dysfunction of the parathyroid glands results in abnormalities in the regulation of
electrolytes, especially calcium. Excessive excretion of parathyroid hormone results in
a state of hypercalcemia. Hyperparathyroidism is frequently associated with significant
psychiatric symptoms, which are caused by the resultant hypercalcemia and can precede
other somatic manifestations of the illness. Patients can experience delirium, sudden
dementia, depression, anxiety, psychosis, apathy, stupor, and coma.
Thyroid disorders
Patients with hyperthyroidism can present in various ways but commonly present with
symptoms of anxiety, confusion, and agitated depression. Patients can also present
with hypomania and frank psychosis. In most patients who present with depression or
anxiety associated with hyperthyroidism without other psychiatric history, psychiatric
symptoms usually resolve with treatment of the hyperthyroidism.
Similar to patients with hyperthyroidism, those with hypothyroidism often present with
depression and anxiety.
Adrenal disorders
Adrenal disorders cause changes in the normal secretion of hormones from the adrenal
cortex and may produce significant psychiatric symptoms. Patients with this condition
can exhibit symptoms such as apathy, fatigue, depression, and irritability. Psychosis and
confusion can also develop.
The existence of moderate-to-severe depression in up to 50% of patients with Cushing
syndrome is well documented, with symptoms sometimes severe enough to lead to
42 suicide. Decreased concentration and memory deficits may also be present.
Neuropsychiatric manifestations of patients with lupus have a prevalence of up to 75- Psychotic Disorder Due to
General Medical
90%. Major psychiatric symptoms include depression, emotional lability, delirium, and Condition
psychosis. The presence of severe depression or psychosis is associated with anti-P
antibodies in the serum, which suggests an autoimmune mechanism for inducing mental
symptoms.
Sodium imbalance
This causes irritability, Confusion, Anxiety, Delusions and hallucinations, etc. Without
proper treatment, seizures, stupor, and coma ultimately ensue. Treatment consists of
correcting the serum sodium level at a slow but adequate rate.
The clinical manifestations of stages of hepatic encephalopathy are listed below
Stage I
 Apathy
 Restlessness
 Impaired cognition
 Impaired handwriting
 Reversal of sleep rhythm
Stage II
 Lethargy
 Drowsiness
 Disorientation
 Asterixis
 Beginning of mood swings
 Beginning of behavioural disinhibition
Stage III
 Arousable stupor
 Hyperactive reflexes
 Short episodes of psychiatric symptoms
Stage IV - Coma (responsive only to pain)
Patients may also experience short episodes of depression, hypomania, anxiety, and
obsessive-compulsive symptoms.
Dialysis dementia is a specific syndrome characterised by encephalopathy, dysarthria,
dysphasia, poor memory, depression, paranoia, myoclonic jerking, and seizures.
Vitamin B-1 deficiency
Much more commonly today, thiamine deficiency manifests as Wernicke encephalopathy,
often, but not exclusively, in individuals with heavy and prolonged alcohol use.
Vitamin B-12 deficiency
Deficiency of vitamin B-12 (cobalamin) is the cause of pernicious anemia. Psychiatric
symptoms include depression, fatigue, psychosis, and progressive cognitive impairment
can accompany neurologic symptoms. 43
Schizophrenia and Other Alcohol
Psychotic Disorders
Although volumes have been written concerning the pathologic changes in patients who
use alcohol for short and long periods, a brief review is appropriate because patients in
alcohol withdrawal can present with numerous psychiatric symptoms that can be fatal if
not identified and treated quickly.
Withdrawal symptoms can emerge, particularly in the absence of a measurable blood
alcohol level. Florid delirium tremens (DT) is the most serious and potentially fatal
alcohol withdrawal syndrome. The clinical picture includes hallucinations (most commonly
auditory and/or visual), gross confusion and disorientation, and autonomic hyperactivity
(e.g, tachycardia, fever, sweating, hypertension). These patients are often agitated and
paranoid and may not readily allow physical examination. The temptation to view an
agitated, paranoid, overtly hallucinating patient as in need of nothing further than admission
to a psychiatric unit may be a grave mistake because untreated DT is potentially fatal.
Patients may also present with hallucinations in a clear sensorium (differentiating it from
DT), usually in the setting of recent cessation of or significant decrease in the amount of
alcohol used. Known as alcoholic hallucinosis, the hallucinations (most frequently
auditory) may be relatively brief, usually resolving within approximately 30 days, but
they may persist. Recurrences are likely with continued alcohol use.
Cocaine and amphetamines
Cocaine is a powerful stimulant initially causing euphoria and increased alertness and
energy. As the high wears off, the user may develop symptoms of anxiety and depression,
often with drug craving. With continued regular use, symptoms of psychosis develop
with hallucinations and frank paranoid delusions. The psychiatric presentation can appear
similar to that observed in patients with chronic amphetamine abuse.
Hallucinogens
A brief mention must be made of lysergic acid diethylamide (LSD), a potent hallucinogen
that causes intense and vivid hallucinations in a clear sensorium. LSD-elicited
hallucinations are usually of relatively short duration, but flashbacks of varying intensity
may occur in a small number of users.
Ecstasy
Depression, anxiety, and psychosis have also been described with regular use, and
some of the symptoms persist for months after cessation of use.
Solvents
Long-term and heavy use can lead to hallucinations, cognitive impairment, personality
change, and neurologic impairment, particularly cerebellar findings.
Heavy metals
Lead, mercury, manganese, arsenic, organophosphorus compounds, and others can
cause psychiatric symptoms. Exposure is usually industrial or environmental and should
be considered in the appropriate settings.
Self Assessment Questions
1) Describe seizure disorder in terms of producing psychotic symptoms.
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44 .....................................................................................................................
 Psychotic Disorder Due to
2) What role brain tumors play in producing psychotic symptoms? General Medical
Condition
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3) How does multiple sclerosis affect the medical condition and produce psychotic
symptoms?
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4) Discuss thyroid disorder and the production of psychotic symptoms.
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5) How does sodium imbalance contribute to psychiatric disorders. Describe the
stages?
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6) Which are the vitamin deficiencies cause psychiatric disorders? Explain.
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7) How do amphetamines, solvents and hallucinogens produce psychotic symptoms?
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45
Schizophrenia and Other
Psychotic Disorders 3.3 SYMPTOMS OF PSYCHOTIC DISORDERS
In a psychotic disorder, perception and understanding of reality is severely impaired.
Symptoms may include fixed but untrue beliefs (delusions), seeing visions or hearing
voices (hallucinations), confusion, disorganised speech, exaggerated or diminished
emotions, or bizarre behaviour. Level of functioning may be severely impaired with
social withdrawal and inability to attend to work, relationships, or even basic personal
care. Individuals generally have little awareness of the mental abnormalities associated
with their illness. It may be impossible to identify a specific psychotic disorder due to
insufficient information or contradictory findings. Psychotic symptoms are described as
positive or negative.
1) Positive symptoms
Positive symptoms are delusions, hallucinations, bizarre behaviours, and thought
broadcasting where the individual believes others can supernaturally influence his or her
thoughts or vice versa.
2) Negative symptoms
Negative symptoms refer to a reduction or loss of normal functions such as restriction
and flattening of emotions, severely reduced speech or thought, and lack of interest in
goal-directed activities. A delusion is a firm belief that others cannot verify.
The delusional individual clings to the belief despite evidence to the contrary. A common
type of delusion involves thoughts of persecution such as being spied upon or conspired
against. There may also be delusions of grandeur where individuals believe they have
extraordinary powers, are on a special mission, or think they are someone important
such as Jesus Christ. The delusion is termed bizarre if it is not based on ordinary life
experiences. An example is of aliens controlling an individual’s body and / or thoughts.
Hallucinations are sensory perceptions that no one else can detect and can involve the
sense of sight, touch, hearing, smell, or taste. Hearing voices is the most frequent
hallucination in psychosis. The hallucinations occur when the individual is awake.
Disorganised thoughts (loosening of associations) are characterised by jumping from
one topic to another. Grossly disorganised behaviour can result in neglect of personal
appearance and hygiene, proper nutrition, and other tasks of living.
The individual may dress inappropriately and act unpredictably such as shouting or
swearing in public. Usually these disorders involve hallucinations or delusions that are
very prominent. Psychosis is a symptom or feature of mental illness typically characterised
by radical changes in personality, impaired functioning, and a distorted or non-existent
sense of objective reality. Patients suffering from psychosis have impaired reality testing;
that is, they are unable to distinguish personal, subjective experience from the reality of
the external world. They experience hallucinations and/or delusions that they believe
are real, and may behave and communicate in an inappropriate and incoherent fashion.
Psychosis may appear as a symptom of a number of mental disorders, including mood
and personality disorders. It is also the defining feature of schizophrenia, schizophreniform
disorder, schizoaffective disorder, delusional disorder, and the psychotic disorders (i.e.,
brief psychotic disorder, shared psychotic disorder, psychotic disorder due to a general
medical condition, and substance induced psychotic disorder. Psychosis may be caused
by the interaction of biological and psychosocial factors depending on the disorder it
presents. Psychosis can also be caused by purely social factors, with no biological
component.
46
3.3.1 Types of Psychotic Disorders Psychotic Disorder Due to
General Medical
According to the Diagnostic and Statistical Manual of Mental Disorders (2000), text Condition
revision (DSM IV TR), there is not an universal acceptance of the term psychotic,
however the DSM IV TR definition refers to the existence of specific symptoms such
as delusions, prominent hallucinations, disorganised speech, disorganised or catatonic
behaviour. In layman’s terms a psychotic individual could be described as someone
who is “insane.”
DSM IV TR is a manual that classifies and describes in great detail all mental disorders
and is highly used in clinical, educational, and research settings. The manual further
describes all of the psychotic disorders in greater detail. Those disorders are:
Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder, Delusional
Disorder, Brief Psychotic Disorder, Shared Psychotic Disorder, Psychotic Disorder
Due to a General Medical Condition, Substance-Induced Psychotic Disorder, and
Psychotic Disorder Not Otherwise Specified.
1) Schizophrenia
Schizophrenia is probably the one that most people are familiar with because it is seen
most commonly in society and in the clinical setting. Schizophrenia is characterised as
being a psychotic disorder that has to last for at least 6 months and include two or more
of active phase symptoms (i.e. hallucinations or delusions) for at least 1 month.
2) Schizophreniforn disorder
Schizophreniform Disorder is very similar to Schizophrenia except that it lasts from 1 to
6 months and also there ‘t have to be a decline in functioning.
3) Schizoaffective disorder
Schizoaffective Disorder is characterised by an individual having a mood episode and
the active phase symptoms of Schizophrenia at the same time. Also there must have
been at least 2 weeks of delusions or hallucinations (without mood symptoms) before
or after the occurrence of them together.
4) Delusional disorder
An individual with Delusional Disorder must have had at least 1 month of non-bizarre
symptoms without any other active phase symptoms. Brief Psychotic Disorder must
last more than 1 day and goes away by 1 month. An individual with Shared Psychotic
Disorder has delusions that have been influenced by someone else who has similar
delusions.
A Psychotic Disorder Due to a General Medical Condition is due to direct relation
from a physiological condition (i.e. psychosis due to lime disease from a tick bite).
A Substance-Induced Psychotic Disorder are due to a direct physiological condition
from medication, drug abuse, or toxin exposure.
Psychotic Disorder Not Otherwise Specified is included in this section to describe all
Psychotic Disorders that do not fit into any of the above criteria or when there is not
enough information or contradictory information provided. Brief psychotic disorder is a
short-term, time-limited disorder. An individual with brief psychotic disorder has
experienced at least one of the major symptoms of psychosis for less than one month.
Hallucinations, delusions, strange bodily movements or lack of movements (catatonic
behaviour), peculiar speech and bizarre or markedly inappropriate behaviour are all
47
classic psychotic symptoms that may occur in brief psychotic disorder.
Schizophrenia and Other 3.3.2 Causes of Psychotic Disorder
Psychotic Disorders
The cause of the symptoms helps to determine whether or not the sufferer is described
as having brief psychotic disorder. If the psychotic symptoms appear as a result of a
physical disease, a reaction to medication, or intoxication with drugs or alcohol, then
the unusual behaviours are not classified as brief psychotic disorder.
If hallucinations, delusions, or other psychotic symptoms occur at the same time that an
individual is experiencing major clinical depression or bipolar (manic-depressive)
disorder, then the brief psychotic disorder diagnosis is not given. The decision rules that
allow the clinician to identify this cluster of symptoms as brief psychotic disorder are
outlined in the Diagnostic and Statistical Manual of the Fourth Edition Text Revision,
produced by the American Psychiatric Association. This manual is referred to by most
mental health professionals as DSM-IV-TR.
Psychosis (from the Greek “psyche”, for mind/soul, and “-osis”, for abnormal condition)
means abnormal condition of the mind, and is a generic psychiatric term for a mental
state often described as involving a “loss of contact with reality”. People suffering from
psychosis are described as psychotic. Psychosis is given to the more severe forms of
psychiatric disorder, during which hallucinations and delusions and impaired insight may
occur. Some professionals say that the term psychosis is not sufficient as some illnesses
grouped under the term “psychosis” have nothing in common (Gelder, Mayou & Geddes
2005).
People experiencing psychosis may report hallucinations or delusional beliefs, and may
exhibit personality changes and thought disorder. Depending on its severity, this may be
accompanied by unusual or bizarre behaviour, as well as difficulty with social interaction
and impairment in carrying out the daily life activities. A wide variety of central nervous
system diseases, from both external poisons and internal physiologic illness, can produce
symptoms of psychosis. Trauma and stress can cause a short-term psychosis (less than
a month’s duration) known as brief psychotic disorder. Major life-changing events such
as the death of a family member or a natural disaster have been known to stimulate
brief psychotic disorder in patients with no prior history of mental illness.
Psychosis may also be triggered by an organic cause, termed a psychotic disorder due
to a general medical condition. Organic sources of psychosis include neurological
conditions (for example, epilepsy and cerebrovascular disease), metabolic conditions
(for example, porphyria), endocrine conditions (for example, hyper- or hypothyroidism),
renal failure, electrolyte imbalance, or autoimmune disorders. Common such underlying
medical conditions are: thyroid disease with too much or too little thyroid hormone
production; brain tumor; stroke; infection of central nervous system; epilepsy; liver or
kidney disease; systemic lupus erythematosus with central nervous system involvement;
severe fluid and electrolyte disturbances; metabolic conditions affecting blood sugar or
oxygen content of the blood. There are more, but these illustrate the point. For instance,
in temporal lobe epilepsy it is common to have the occasional patient develop religious
delusions.
Other hallucinations associated with temporal lobe epilepsy are olfactory hallucinations
such as smelling burning rubber or other unpleasant smells. In some patients the medical
diagnosis is known and the hallucinations develop subsequently. In other patients the
hallucinations are the first clue that there may be an underlying medical condition. If the
psychotic condition starts at an age atypical for a psychotic disorder and visual or
olfactory hallucinations are present, the clinician must think about a medical condition
(or hidden drug abuse) that may cause these symptoms.
48
 Psychotic Disorder Due to
Self Assessment Questions General Medical
Condition
1) What are the positive and negative symptoms of psychotic disorders?
.....................................................................................................................
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2) Describe hallucinations and delusions.
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3) What are the various types of psychotic disorders?
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4) What are the causes of psychotic disorders? Explain.
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3.4 SYMPTOMS OF PSYCHOTIC DISORDERS DUE

TO MEDICAL CONDITION
Psychosis is characterised by the following symptoms:
1) Delusions
An unshakable and irrational belief in something untrue. Delusions defy normal reasoning,
and remain firm even when overwhelming proof is presented to disprove them.
2) Hallucinations
Psychosis causes false or distorted sensory experience that appear to be real. Psychotic
patients often see, hear, smell, taste, or feel things that aren’t there.
3) Disorganised speech
Psychotic patients often speak incoherently, using noises instead of words and “talking”
in unintelligible speech patterns.
49
Schizophrenia and Other 4) Disorganised or catatonic behaviour
Psychotic Disorders
Behavior that is completely inappropriate to the situation or environment. Catatonic
patients have either a complete lack of or inappropriate excess of motor activity. They
can be completely rigid and unable to move (vegetative), or in constant motion.
Disorganised behaviour is unpredictable and inappropriate for a situation (e.g., screaming
obscenities in the middle of class).

3.4.1 Symptoms
The main symptoms of this disorder are delusions and hallucinations. There has to be
medical evidence that the symptoms are a direct physiological consequence of a medical
condition. All other mental disorders have to be ruled out before this diagnosis is given.
There are many medical conditions that can cause psychotic symptoms. These medical
conditions include; epilepsy, multiple sclerosis, central nervous system infections and
migraines. There are two subtypes of this disorder. The two subtypes are:
Delusions: The person has delusions. A delusion is a fixed belief that is either false,
fanciful, or derived from deception. In psychiatry, it is defined to be a belief that is
pathological (the result of an illness or illness process) and is held despite evidence to
the contrary. As a pathology, it is distinct from a belief based on false or incomplete
information, dogma, stupidity, poor memory, illusion, or other effects of perception.
Delusions typically occur in the context of neurological or mental illness, although they
are not tied to any particular disease and have been found to occur in the context of
many pathological states (both physical and mental). However, they are of particular
diagnostic importance in psychotic disorders.

3.4.2 Types of Delusions

Delusions are categorised into different groups:
1) Bizarre delusion: A delusion that is very strange and completely implausible; an
example of a bizarre delusion would be that aliens have removed the affected
person’s brain.
2) Non-bizarre delusion: A delusion that, though false, is at least possible, e.g., the
affected person mistakenly believes that he is under constant police surveillance.
3) Mood-congruent delusion: Any delusion with content consistent with either a
depressive or manic state, e.g., a depressed person believes that news anchors on
television highly disapprove of him, or a person in a manic state might believe he is
a powerful deity.
4) Mood-neutral delusion: A delusion that does not relate to the sufferer’s emotional
state; for example, a belief that an extra limb is growing out of the back of one’s
head is neutral to either depression or mania.
5) Delusion of control: This is a false belief that another person, group of people, or
external force controls one’s thoughts, feelings, impulses, or behaviour.
6) Nihilistic delusion: A person with this type of delusion may have the false belief
that the world is ending.
7) Delusional jealousy (or delusion of infidelity): A person with this delusion falsely
believes a spouse or lover is having an affair.
8) Delusion of guilt or sin (or delusion of self-accusation): This is a false feeling of
50
remorse or guilt of delusional intensity.
9) Delusion of mind being read: The false belief that other people can know one’s Psychotic Disorder Due to
General Medical
thoughts. Condition

10) Delusion of reference: The person falsely believes that insignificant remarks, events,
or objects in one’s environment have personal meaning or significance.
11) Erotomania: A delusion where someone believes another person is in love with
them.
12) Grandiose delusion: An individual is convinced he has special powers, talents, or
abilities. Sometimes, the individual may actually believe he or she is a famous
person or character (for example, a rock star).
13) Persecutory delusion: These are the most common type of delusions and involve
the theme of being followed, harassed, cheated, poisoned or drugged, conspired
against, spied on, attacked, or obstructed in the pursuit of goals.
14) Religious delusion: Any delusion with a religious or spiritual content. These may
be combined with other delusions, such as grandiose delusions (the belief that the
affected person is a god, or chosen to act as a god, for example).
15) Somatic delusion: A delusion whose content pertains to bodily functioning, bodily
sensations, or physical appearance. Usually the false belief is that the body is
somehow diseased, abnormal, or changed—for example, infested with parasites.
16) Delusions of parasitosis (DOP) or delusional parasitosis: a delusion in which
one feels infested with an insect, bacteria, mite, spiders, lice, fleas, worms, or
other organisms. Affected individuals may also report being repeatedly bitten. In
some cases, entomologists are asked to investigate cases of mysterious bites.
Sometimes physical manifestations may occur including skin lesions.
17) Delusions of poverty: The person strongly believes that he is financially
incapacitated. Although this type of delusion is less common now, it is however
interesting to note that it was particularly widespread in the days before state
support

3.4.3 Hallucinations
The person has Hallucinations. Hallucinations can occur in any sensory modality (i.e.,
visual, olfactory, gustatory, tactile, or auditory), but certain etiological factors are likely
to evoke specific hallucinatory phenomena. Olfactory hallucinations, especially those
involving the smell of burning rubber or other unpleasant smells, are highly suggestive of
temporal lobe epilepsy. Hallucinations may vary from simple and unformed to highly
complex and organised, depending on etiological factors, environmental surroundings,
nature and focus of the insult rendered to the central nervous system, and the reactive
response to impairment The latter definition distinguishes hallucinations from the related
phenomena of dreaming, which does not involve wakefulness; illusion, which involves
distorted or misinterpreted real perception; imagery, which does not mimic real
perception and is under voluntary control; and pseudohallucination, which does not
mimic real perception, but is not under voluntary control.[1] Hallucinations also differ
from “delusional perceptions”, in which a correctly sensed and interpreted genuine
perception is given some additional (and typically bizarre) significance.
Hallucinations can occur in any sensory modality — visual, auditory, olfactory, gustatory,
tactile, proprioceptive, equilibrioceptive, nociceptive, thermoceptive and chronoceptive.
51
Schizophrenia and Other
Psychotic Disorders Self Assessment Questions
1) What are the various symptoms of pschotic disorders due to medical conditions?
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2) Describe the symptoms of this disorder.
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3) What are the various types of delusions?
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4) Define hallucinations.
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5) What are the various types of hallucinations?
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3.5 CAUSES PSYCHOTIC DISORDERS DUE TO

MEDICAL CONDITIONS
Psychosis may be caused by a number of biological and social factors, depending on
the disorder underlying the symptom. Trauma and stress can induce a short-term
psychosis known as brief psychotic disorder. This psychotic episode, which lasts a
month or less, can be brought on by the stress of major life-changing events (e.g., death
of a close friend or family member, natural disaster, traumatic event), and can occur in
patients with no prior history of mental illness.
52
Psychosis can also occur as a result of an organic medical condition (known as psychotic Psychotic Disorder Due to
General Medical
disorder due to a general medical condition). Neurological conditions (e.g., epilepsy, Condition
migraines, Parkinson’s disease, cerebrovascular disease, dementia), metabolic
imbalances (hypoglycemia), endocrine disorders (hyper- and hypothyroidism), renal
disease, electrolyte imbalance, and autoimmune disorders may all trigger psychotic
episodes.
Hallucinogenics, PCP, amphetamines, cocaine, marijuana, and alcohol may cause a
psychotic reaction during use, abuse, or withdrawal. Certain prescription medications
such as anesthetics, anticonvulsants, chemotherapeutic agents, and antiparkinsonian
medications may also induce psychotic symptoms as a side-effect. In addition, toxic
substances like carbon dioxide and carbon monoxide, which may be deliberately or
accidentally ingested, have been reported to cause substance-induced psychotic
disorder.

3.5.1 Functional Causes

Functional causes of psychosis include the following:
 brain tumors
 drug abuse amphetamines, cocaine, marijuana, alcohol among others
 brain damage
 schizophrenia, schizophreniform disorder, schizoaffective disorder, brief psychotic
disorder
 bipolar disorder (manic depression)
 severe clinical depression
 severe psychosocial stress
 sleep deprivation
 some focal epileptic disorders especially if the temporal lobe is affected
 exposure to some traumatic event (violent death, etc.)
 abrupt or over-rapid withdrawal from certain recreational or prescribed drugs.
A psychotic episode can be significantly affected by mood. For example, people
experiencing a psychotic episode in the context of depression may experience
persecutory or self-blaming delusions or hallucinations, while people experiencing a
psychotic episode in the context of mania may form grandiose delusions.
Stress is known to contribute to and trigger psychotic states. A history of psychologically
traumatic events, and the recent experience of a stressful event, can both contribute to
the development of psychosis. Short-lived psychosis triggered by stress is known as
brief reactive psychosis, and patients may spontaneously recover normal functioning
within two weeks.
In some rare cases, individuals may remain in a state of full-blown psychosis for many
years, or perhaps have attenuated psychotic symptoms (such as low intensity
hallucinations) present at most times.

3.5.2 General Medical Conditions

Psychosis arising from “organic” (non-psychological) conditions is sometimes known
as secondary psychosis. It can be associated with the following pathologies:
53
Schizophrenia and Other  neurological disorders, including:
Psychotic Disorders
 brain tumour
 dementia with Lewy bodies
 multiple sclerosis
 sarcoidosis
 Lyme Disease
 syphilis
 Alzheimer’s Disease
 Parkinson’s Disease.

3.5.3 Psychoactive Drugs

Various psychoactive substances (both legal and illegal) have been implicated in causing,
exacerbating, and/or precipitating psychotic states and/or disorders in users. On the
other hand, cannabis use has increased dramatically over the past few decades but
declined in the last decade, whereas the rate of psychosis has not increased.
An early phase of schizophrenia.
Because of the similarities between brief psychotic disorder, schizophreniform disorder
and schizophrenia, many clinicians have come to think of brief psychotic disorder as
being the precursor to a lengthier psychotic disorder. Although this can only be identified
retrospectively, brief psychotic disorder is often the diagnosis that was originally used
when an individual (who later develops schizophrenia) experiences a first “psychotic
break” from more typical functioning.

3.5.4 A Stress Response

At times, under severe stress, temporary psychotic reactions may appear. The source
of stress can be from typical events encountered by many people in the course of a
lifetime, such as being widowed or divorced. The severe stress may be more unusual,
such as being in combat, enduring a natural disaster, or being taken hostage. The person
generally returns to a normal method of functioning when the stress decreases or more
support is available, or better coping skills are learned.

3.5.5 Postpartum Psychosis

In some susceptible women, dramatic hormonal changes in childbirth and shortly
afterward can result in a form of brief psychotic disorder often referred to as postpartum
psychosis. Unfortunately, postpartum conditions are often misidentified and improperly
treated. In many cases of a mother killing her infant or committing suicide , postpartum
psychosis is involved.
Self Assessment Questions
1) What are the causes of psychosis in generalmedical conditions?
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54 .....................................................................................................................
 Psychotic Disorder Due to
2) What are psychoactive drugs? How are they involved in producing psychotic General Medical
symptoms? Condition

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3) Descrfibe a stress response in the context psychotic symptoms.
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3.6 DEFENSE MECHANISM IN PERSONALITY

DISORDER
Persons with personality disorders appear to be more susceptible to developing
brief psychotic reactions in response to stress. Individuals with personality disorders
have not developed effective adult mechanisms for coping with life. When life becomes
more demanding and difficult than can be tolerated, the person may lapse into a brief
psychotic state.

3.6.1 Culturally Defined Disorder

Culture is a very important factor in understanding mental health and psychological
disturbance, and brief psychotic disorder is an excellent example. The types of behaviour
that occur during brief psychotic disorder are very much shaped by the expectations
and traditions of the individual’s culture. Many cultures have some form of mental
disorder that would meet criteria for brief psychotic disorder the features of which are
unique to that culture, wherein most sufferers have similar behaviours that are attributed
to causes that are localised to that community. The DSMIV-TR calls disorders unique
to certain societies or groups “culture-bound.”
An example of a culture-bound syndrome is koro, a syndrome observed in Japan and
some other areas of Asia but not elsewhere. Koro is an obsession to the point of
delusion with the possibility that the genitals will retract or shrink into the body and
cause death.
Conversely, while culture shapes the form a psychotic reaction may take, culture also
determines what is not to be considered psychotic. Behaviours that in one culture
would be thought of as bizarre or psychotic, may be acceptable in another. For example,
some cultural groups and religions view “speaking in tongues” as a valuable expression
of the gifts of God, whereas viewed out of context, the unrecognisable speech patterns
might be viewed as psychotic. If the behaviours shown are culturally acceptable in the
person’s society or religion, and happen in an approved setting such as a religious
service, then brief psychotic disorder would not be diagnosed.

55
Schizophrenia and Other
Psychotic Disorders 3.7 TREATMENT
The treatment of psychosis depends on the cause or diagnosis or diagnoses (such as
schizophrenia, bipolar disorder and/ or substance intoxication). The first line treatment
for many psychotic disorders is antipsychotic medication (oral or intramuscular injection),
and sometimes hospitalisation is needed. There is growing evidence that cognitive
behaviour therapy and family therapy can be effective in managing psychotic symptoms.

3.7.1 Early Intervention

Early intervention in psychosis is a relatively new concept based on the observation that
identifying and treating someone in the early stages of a psychosis can significantly
improve their longer term outcome. This approach advocates the use of an intensive
multi-disciplinary approach during what is known as the critical period, where intervention
is the most effective, and prevents the long term morbidity associated with chronic
psychotic illness.
Newer research into the effectiveness of cognitive behavioural therapy during the early
pre-cursory stages of psychosis (also known as the “prodrome” or “at risk mental
state”) suggests that such input can prevent or delay the onset of psychosis.

3.7.2 Hospitalisation
Hospitalisation is preferred when dealing with patients who exhibit severe symptoms of
Schizophrenia. The aim of hospitalisation is to prevent them from hurting or injuring
themselves and gain stability as they take medication.
Psychiatric hospitalisation may be needed to observe individuals and protect them from
their own loss of reality, judgment, and impulse control. Antipsychotic medication may
be given along with any appropriate psychotherapy. In certain situations, group therapy
may be effective. Electroconvulsive therapy (ECT) is not as effective. Fifty to sixty
percent of cases get better with ECT if the patient has a psychotic disorder (Ghaziuddin
119). With continued observation, it may be possible to reach a more specific diagnosis
and initiate appropriate treatment. Psychosis caused by schizophrenia or another mental
illness should be treated by a psychiatrist and/or psychologist. Other medical and mental
health professionals may be part of the treatment team, depending on the severity of the
psychosis and the needs of the patient. Medication and/or psychosocial therapy is
typically employed to treat the underlying disorder.

3.7.3 Medications
Antipsychotic medications commonly prescribed to treat psychosis include risperidone
(Risperdal), thioridazine (Mellaril), halperidol (Haldol), chlorpromazine (Thorazine),
clozapine (Clozaril), loxapine (Loxitane), molindone hydrochloride (Moban), thiothixene
(Navane), and olanzapine (Zyprexa). Possible common side-effects of antipsychotics
include dry mouth, drowsiness, muscle stiffness, and hypotension. More serious side
effects include tardive dyskinesia (involuntary movements of the body) and neuroleptic
malignant syndrome (NMS), a potentially fatal condition characterised by muscle rigidity,
altered mental status, and irregular pulse and blood pressure.
Once an acute psychotic episode has subsided, psychosocial therapy and living and
vocational skills training may be recommended. Drug maintenance treatment is usually
prescribed to prevent further episodes.
Antipsychotics are the primary medications for treating schizophrenia. This medicine
56
reduces disturbing symptoms like hallucinations and delusion. Some of the common Psychotic Disorder Due to
General Medical
medicines include Prolixin, Navane, Trilafon, Clozaril, Geodon and Zyprexa. Condition

3.7.4 Psychosocial Therapy

Psychosocial therapy is considered the most effective in dealing with social, psychological
and behavioural problems resulting from schizophrenia. Therapy includes rehabilitation
which helps an individual to focus on skills and training to help an individual to be
independent. Family therapy enables a person to interact and effectively deal with the
family members.

3.8 LET US SUM UP

Thus it can be said that psychosis caused by a medical condition may be a single
isolated incident or may be recurrent, cycling with the status of the underlying medical
condition. Although treating the medical condition often results in the remission of the
psychosis. The symptoms of psychosis sometimes persists long after the medical
conditions and caused psychosis. Prominent hallucinations and delusions are the main
cause for such psychotic development. Individuals with brief psychotic disorder
experience delusions, hallucinations, and/or disorganised speech and behaviour that
lasts for at least one day. However, these symptoms remit within one month, and their
behaviour returns to normal. If the observed psychotic symptoms can be reasonably
thought to have been due to a pre-existing mental illness diagnosis .
About 1% of the world’s population has psychotic disorders. Symptoms for most
psychotic disorders often first appear when an individual is in their late teens to 30’s.
Psychotic disorders affect men and women equally. Men more commonly develop
symptoms of schizophrenia between 18 to 25 years old, while women tend to develop
symptoms of schizophrenia between 25 years old to the mid 30’s. Late onset (after 40
years old) is more common in women then in men. In psychosis persons with some
preexisting vulnerability experience some stress and symptoms emerge as a result.
Psychotic symptoms disrupt the lives and this need to be handle with the interventions
like therapy,medications and early identification of the disorder.

3.9 UNIT END QUESTIONS

1) What are the symptoms of psychotic disorders due to general medical conditions?
2) What are the causes of psychotic disorders due to medical conditions?
3) What is meant by defense mechanisms in psychotic disorders?
4) What do we understand by culturally defined disorders?
5) Describe the early intervention as part of treatment of these disorders.
6) When are these patients hospitalised and what are the main reasons for the same?
7) Discuss the psychosocial therapy for psychotic disorders due to general medical
condition.

3.10 SUGGESTED READINGS AND REFERENCES

Psychotic Disorders: A Practical Guide (Practical Guides in Psychiatry) pub Lippincott
Williams and Wilkins
57
Schizophrenia and Other Daryl Fujii and Iqbal Ahmed (Eds)(2007). The Spectrum of Psychotic Disorders:
Psychotic Disorders
Neurobiology, Etiology & Pathogenesis, Cambridge University Press, London.
Findling , Robert, S.Charles Schulz, Javad, H.Kashani and Elena Harlan (Eds) (2001).
Psychotic Disorders in Children and Adolescents. Sage publications, California.
Michael Gelder, Nancy Andreason, Juan Lopez-Ibor, and John Geddes (2009). New
Oxford Textbook of Psychiatry. (2nd edition). Oxford University Press, London.
References
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental
Disorders Fourth Edition, Text Revision. American Pyschiatric Association, Washington,
DC
Beer, M D (1995). “Psychosis: from mental disorder to disease concept”. Hist Psychiatry
6 (22(II)): 177–200.
Berrios G E (1987). “Historical Aspects of Psychoses: 19th Century Issues”. British
Medical Bulletin 43 (3): 484–498.
Berrios G E, Beer D (1994). “The notion of Unitary Psychosis: a conceptual history”.
History of Psychiatry 5 (17 Pt 1): 13–36.
Birchwood, M; P. Todd, C. Jackson (1998). “Early Intervention in Psychosis: The
Critical Period Hypothesis”. British Journal of Psychiatry 172 (33): 53–59.
Birchwood, M; Trower P (2006). “The future of cognitive-behavioural therapy for
psychosis: not a quasi-neuroleptic”. British Journal of Psychiatry 188: 108–108.
French, Paul; Anthony Morrison (2004). Early Detection and cognitive therapy for
people at high risk of developing psychosis. Chichester: John Wiley and Sons.
Gelder, Michael (2005). “Psychiatry”, P. 12. Oxford University Press Inc., New York.
Haddock, G; Lewis S (2005). “Psychological interventions in early psychosis”.
Schizophrenia Bulletin 31 (3): 697–704..
Harper, Douglas (November 2001). “hallucinate”. Online Etymology Dictionary.
Hinshaw, S.P. (2002) The Years of Silence are Past: My Father’s Life with Bipolar
Disorder. Cambridge: Cambridge University Press.
Honig A, Romme MA, Ensink BJ, Escher SD, Pennings MH, deVries MW (October
1998). “Auditory hallucinations: a comparison between patients and nonpatients”. J.
Nerv. Ment. Dis. 186 (10): 646–51
Jaspers, Karl (1997-11-27) [1963]. Allgemeine Psychopathologie (General
Psychopathology). Translated by J. Hoenig & M.W. Hamilton from German (Reprint
ed.). Baltimore, Maryland: Johns Hopkins University Press.
Jauch, D. A.; William T. Carpenter, Jr. (February 1988). “Reactive psychosis. I. Does
the pre-DSM-III concept define a third psychosis?”. Journal of Nervous and Mental
Disease 176 (2): 72–81.
Lesser JM, Hughes S (December 2006). “Psychosis-related disturbances. Psychosis,
agitation, and disinhibition in Alzheimer’s disease: definitions and treatment options.
Leweke FM, Koethe D (June 2008). “Cannabis and psychiatric disorders: it is not
58 only addiction”. Addict Biol 13 (2): 264–75.
McKeith, Ian G. (February 2002). “Dementia with Lewy bodies”. British Journal of Psychotic Disorder Due to
General Medical
Psychiatry 180: Condition

Nathans-Barel, I.; P. Feldman, B. Berger, I. Modai and H. Silver (2005). “Animal-

assisted therapy ameliorates anhedonia in schizophrenia patients”. Psychotherapy and
Psychosomatics 74 (1): 31–35.
Ohayon, M. M.; R. G. Priest, M. Caulet, and C. Guilleminault (October 1996).
“Hypnagogic and hypnopompic hallucinations: pathological phenomena?”. British Journal
of Psychiatry 169 (4): 459–67
Sethi NK, Robilotti E, Sadan Y (2005). “Neurological Manifestations Of Vitamin B-
12 Deficiency”. The Internet Journal of Nutrition and Wellness .
Sims, A. (2002) Symptoms in the mind: An introduction to descriptive psychopathology
(3rd edition). Edinburgh: Elsevier Science Ltd.
Tien AY, Anthony JC (August 1990). “Epidemiological analysis of alcohol and drug use
as risk factors for psychotic experiences”. J. Nerv. Ment. Dis. 178 (8): 473–80

59
 UNIT 4 SUBSTANCE INDUCED
PSYCHOTIC DISORDER
Structure
4.0 Introduction
4.1 Objectives
4.2 Substance Induced Psychotic Disorders
4.2.1 Causes of Substance Induced Psychotic Disorders
4.2.2 Diagnosis of Substance Induced Psychotic Disorder
4.2.3 Essential Features of Substance Induced Psychotic Disorders
4.2.4 Difference Between Substance Induced Psychotic Disorders and Other Psychotic
Disorders

4.3 Subtypes and Specifiers

4.4 Diagnosis
4.4.1 Differential Diagnosis of Substance Induced Psychotic Disorder and Medicine Induced
Psychotic Disorders

4.5 Treatments
4.5.1 Hospitalisation
4.5.2 Medical Care
4.5.3 Counselling
4.5.4 Detoxification
4.5.5 Surgical Care
4.5.6 Medications
4.5.7 Prognosis
4.5.8 Prevention

4.6 Let Us Sum Up

4.7 Unit End Questions
4.8 Suggested Readings

4.0 INTRODUCTION
In this unit we will be dealing with substance induced psychotic disorders. We begin
with substance induced psychotic disorders in terms of what are psychotic disorders
and what types of such disorders exist . This is followed by the type of substances that
could induce these disorders. The various causes that lead to psychoactive substances
and their effects resulting in psychotic reactions are discussed. This is followed by
diagnostic criteria to decide the substance induced psychotic disorder . We then present
the essential features of substance induced psychotic disorders and bring out the
differences between these disorders and the medically induced psychotic disorders.
This is followed by the subtypes of these disorders and the specifiers. We then use
different criteria to diagnose these disorders and make a differential diagnosis of these
disorder vis a vis other psychotic disorders. Then we take up the treatments of these

60
disorders which includes hospitalisation onwards to medical care, counseling and surgical Substance Induced
Psychotic Disorder
care. The prognosis and prevention are discussed briefly.

4.1 OBJECTIVES
After completing this unit, you will be able to:
 Define substance induced psychotic disorder;
 Enlist various types of such psychotic disorders;
 Delineate the Symptoms and causes of the disorders;
 Explain the differential diagnosis of substance induced psychotic disorders vis a
vis other psychotic disorders; and
 Analyse the different treatment approaches to these disorders.

4.2 SUBSTANCE INDUCED PSYCHOTIC

DISORDER
Let us start with psychotic disorders.
Psychotic disorders are a group of serious illnesses that affect the mind. These illnesses
alter a person’s ability to think clearly, make good judgments, respond emotionally,
communicate effectively, understand reality, and behave appropriately. When symptoms
are severe, people with psychotic disorders have difficulty staying in touch with reality
and often are unable to meet the ordinary demands of daily life. However, even the
most severe psychotic disorders usually are treatable.
There are different types of psychotic disorders, including:
Schizophrenia: People with this illness have changes in behaviour and other symptoms
— such as delusions and hallucinations — that last longer than six months, usually with
a decline in work, school and social functioning.
Schizoaffective disorder: People with this illness have symptoms of both schizophrenia
and a mood disorder, such as depression or bipolar disorder.
Schizophreniform disorder: People with this illness have symptoms of schizophrenia,
but the symptoms last more than one month but less than six months.
Brief psychotic disorder: People with this illness have sudden, short periods of psychotic
behaviour, often in response to a very stressful event, such as a death in the family.
Recovery is often quick — usually less than a month.
Delusional disorder: People with this illness have delusions involving real-life situations
that could be true, such as being followed, being conspired against or having a disease.
These delusions persist for at least one month.
Shared psychotic disorder: This illness occurs when a person develops delusions in the
context of a relationship with another person who already has his or her own delusion(s).
Substance-induced psychotic disorder: This condition is caused by the use of or
withdrawal from some substances, such as alcohol and crack cocaine, that may cause
hallucinations, delusions or confused speech.
Psychotic disorder due to a medical condition: Hallucinations, delusions or other
61
Schizophrenia and Other symptoms may be the result of another illness that affects brain function, such as a head
Psychotic Disorders
injury or brain tumor.
Paraphrenia: This is a type of schizophrenia that starts late in life and occurs in the
elderly population.

4.2.1 Causes of Substance Induced Psychotic Disorders

A large number of toxic or psychoactive substances can cause psychotic reactions.
Such substance induced psychosis can occur in multiple ways.
These include the following:
1) People may inadvertently ingest toxic substances by accident, either because they
do not know any better or by mistake.
2) People may take too much of a legitimately prescribed medicine, medicines may
interact in unforeseen ways. Doctors may miscalculate the effects of medicines
they prescribe.
3) People may overdose on recreational drugs they commonly use (such as cocaine),
or become dependent on drugs or alcohol and experience psychotic symptoms
while in withdrawal from those substances.
4) While the substance induced psychosis is triggered and then sustained by
intoxication or withdrawal, its effects can continue long after intoxication or
withdrawal has ended.
5) Drugs of abuse that can cause psychosis include alcohol, amphetamines, marijuana,
cocaine, hallucinogens, inhalants, opioids, and sedative-hypnotics, including
medicines that are sometimes used to treat anxiety.
6) Common over the counter and doctor prescribed medications that can cause
psychosis include anesthetics, analgesics, anticholinergic agents, anticonvulsants,
antihistamines, cardiovascular medications, antimicrobial medications,
antiparkinsonian medications, chemotherapeutic agents, corticosteroids,
gastrointestinal medications, muscle relaxants, nonsteroidal anti inflammatory
medications like ibuprophin, and anti-depressants.
7) Environmental toxins reported to induce psychotic symptoms include
anticholinesterase, organophosphate insecticides, nerve gases, carbon monoxide
(car exhaust), carbon dioxide, and volatile substances such as fuel or paint.

4.2.2 Diagnosis of Substance Induced Psychotic Disorders

The following diagnostic criteria must be met before a diagnosis of Substance Induced
Psychotic Disorder is warranted. According to the DSM IV TR the symptoms must
be
a) Prominent hallucinations or delusions
b) Evidence from the history, physical examination, or laboratory findings of either
(1) or (2) given below.
1) The symptoms in Criterion A developed during, or within a month of,
substance intoxication or withdrawal
2) Medication use is etiologically related to the disturbance
c) The disturbance is not better accounted for by a Psychotic Disorder that is not
62
substance induced.
If it is other psychotic disorder, the symptoms would include the following: Substance Induced
Psychotic Disorder
i) the symptoms would precede the onset of the substance use (or medication use);
ii) the symptoms persist for a substantial period of time (e.g., about a month) after
the cessation of acute withdrawal or severe intoxication, or
iii) are substantially in excess of what would be expected given the type or amount of
the substance used or the duration of use; or
iv) there is other evidence that suggests the existence of an independent non substance
induced Psychotic Disorder, as for example, a history of recurrent non substance
related episodes.
d) The disturbance does not occur exclusively during the course of a delirium.

4.2.3 Essential Features of Substance Induced Psychotic

Disorders
The essential features of Substance-Induced Psychotic Disorder are prominent
hallucinations or delusions (Criterion A) that are judged to be due to the direct
physiological effects of a substance.
Hallucinations that the individual realises are substance induced are not included here
and instead would be diagnosed as Substance Intoxication or Substance Withdrawal
with the accompanying specifier with Perceptual Disturbances.
The disturbance must not be better accounted for by a Psychotic Disorder that is not
substance induced (Criterion C).
The diagnosis is not made if the psychotic symptoms occur only during the course of a
delirium (Criterion D).
This diagnosis should be made instead of a diagnosis of Substance Intoxication or
Substance Withdrawal only when the psychotic symptoms are in excess of those usually
associated with the intoxication or withdrawal syndrome and when the symptoms are
sufficiently severe to warrant independent clinical attention.

4.2.4 Difference between Substance Induced Psychotic

Disorders and Other Psychotic Disorders
Table below presents the differences between substance induce and other psychotic
disorders.

Substance induced psychotic disorders Other psychotic disorders

Onset: Following ingesting the substance Onset Insidious onset or over a period of
of abuse time. Has nothing to do with any
substance abuse
Course of this disorder is associated with Course of this disorder continues on and
the drug intake. The moment the drug is the symptoms reduce or disappear with
withdrawn, after the period of withdrawal intake of medications
syndrome, the psychotic episodes also
disappear
There must be evidence from the history, Physical examination etc do not show any
physical examination, or laboratory ingestion of drugs. There is no history of
findings of Dependence, Abuse, substance abuse.
intoxication, or withdrawal 63
Schizophrenia and Other
Psychotic Disorders
Substance Induced Psychotic Disorders Other Psychotic disorders do not have any
arise only in association with association with drug or intoxication or
intoxication or withdrawal states withdrawal.
May persist for weeks These precede the onset of substance use or
may occur during times of sustained
abstinence.
Once initiated the psychotic symptoms There is no relationship between psychotic
may continue as long as the substance features and use of substances
use continues
Age of onset has no importance here Age of onset is very important as for
instance the age of onset for schizophrenia
is adolescent years to young adulthood
No specific role of history of psychotic There is history of psychotic disorder at an
disorder earlier age leve or in the family
Generally there is non auditory In this there is generally auditory
hallucinations hallucinations
The psychotic symptoms persist so long Psychotic symptoms persist for a
as the substance abuse continues substantially long period of time
Persistence of psychotic symptoms for a There is no connection between substance
substantial period of time (i.e., a month use or withdrawal symptoms and the
or more) after the end of Substance psychotic features.
Intoxication or acute Substance
Withdrawal.
Symptoms of psychotic disorder are The development of symptoms that are
limited to the use of substance. substantially in excess of what would be
expected given the type or amount of the
substance used or the duration of use.

Other causes of psychotic symptoms must be considered even in a person with

Intoxication or Withdrawal, because substance use problems are not uncommon among
persons with non substance induced Psychotic Disorders.
Self Assessment Questions
1) Describe in detail the various psychotic disorders.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) Define substance induced psychotic disorders.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) What are the criteria to diagnose substance induced psychotic disorders?
.....................................................................................................................
64
 Substance Induced
..................................................................................................................... Psychotic Disorder

.....................................................................................................................
.....................................................................................................................
4) Describe the essential features of substance induced psychotic disorfders.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
5) Differentiate between substance induced psychotic disorder and other psychotic
disorders.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

4.3 SUBTYPES AND SPECIFIERS

One of the following subtypes may be used to indicate the predominant symptom
presentation. If both delusions and hallucinations are present, indicate whichever is
predominant:
With Delusions: This subtype is used if delusions are the predominant symptom.
With Hallucinations: This subtype is used if hallucinations are the predominant symptom.
The context of the development of the psychotic symptoms may be indicated by using
one of the specifiers listed below:
With Onset During Intoxication: This specifier should be used if criteria for intoxication
with the substance are met and the symptoms develop during the intoxication syndrome.
With Onset During Withdrawal: This specifier should be used if criteria for withdrawal
from the substance are met and the symptoms develop during, or shortly after, a
withdrawal syndrome.
A substance induced psychotic disorder that begins during substance use can last as
long as the drug is used. A substance induced psychotic disorder that begins during
withdrawal may first manifest up to four weeks after an individual stops using the
substance.
The speed of onset of psychotic symptoms varies depending on the type of substance.
For example, using a lot of cocaine can produce psychotic symptoms within minutes.
On the other hand, psychotic symptoms may result from alcohol use only after days or
weeks of intensive use.
The type of psychotic symptoms also tends to vary according to the type of substance.
For instance, auditory hallucinations (specifically, hearing voices), visual hallucinations, 65
Schizophrenia and Other and tactile hallucinations are most common in an alcohol-induced psychotic disorder,
Psychotic Disorders
whereas persecutory delusions and tactile hallucinations (especially formication) are
commonly seen in a cocaine – or amphetamine-induced psychotic disorder.

4.4 DIAGNOSIS
Diagnosis of a substance-induced psychotic disorder must be differentiated from a
psychotic disorder due to a general medical condition.
Some medical conditions (such as temporal lobe epilepsy or Huntington’s chorea) can
produce psychotic symptoms, and, since individuals are likely to be taking medications
for these conditions, it can be difficult to determine the cause of the psychotic symptoms.
If the symptoms are determined to be due to the medical condition, then a diagnosis of
a psychotic disorder due to a general medical condition is warranted.
Substance-induced psychotic disorder also needs to be distinguished from delirium,
dementia , primary psychotic disorders, and substance intoxication and withdrawal.
While there are no absolute means of determining substance use as a cause, a good
patient history that includes careful assessment of onset and course of symptoms, along
with that of substance use, is imperative.
Often, the patient’s testimony is unreliable, necessitating the gathering of information
from family, friends, coworkers, employment records, medical records, and the like.
Differentiating between substance-induced disorder and a psychiatric disorder may be
aided by the following:
Time of onset: If symptoms began prior to substance use, it is most likely a psychiatric
disorder.
Substance use patterns: If symptoms persist for three months or longer after substance
is discontinued, a psychiatric disorder is probable.
Consistency of symptoms: Symptoms more exaggerated than one would expect with
a particular substance type and dose most likely amounts to a psychiatric disorder.
Family history: A family history of mental illness may indicate a psychiatric disorder.
Response to substance abuse treatment: Clients with both psychiatric and substance
use disorders often have serious difficulty with traditional substance abuse treatment
programs and relapse during or shortly after treatment cessation.
Client’s stated reason for substance use: Those with a primary psychiatric diagnosis
and secondary substance use disorder will often indicate they “medicate symptoms,”
for example, drink to dispel auditory hallucinations, use stimulants to combat depression,
use depressants to reduce anxiety or soothe a manic phase.
While such substance use most often exacerbates the psychotic condition, it does not
necessarily mean it is a substance-induced psychotic disorder.
Unfortunately, psychological tests are not always helpful in determining if a psychotic
disorder is caused by substance use or is being exacerbated by it. However, evaluations,
such as the MMPI-2and MAC-R scale or the Wechsler Memory Scale—Revised,
can be useful in making a differential diagnosis. Also Neuropsychological assessment
or Neuropsychological testing is also an important tool for examining the effects of
toxic substances on brain functioning. Some physicians may use neuropsychological
66
assessments to reveal patients’ cognitive and physical impairment after cocaine use.
Neuropsychological testing assesses brain functioning through structured and systematic Substance Induced
Psychotic Disorder
behavioural observation. Neuropsychological tests are designed to examine a variety
of cognitive abilities, including speed of information processing, attention, memory, and
language. An example of a task that a physician might ask the patient to complete as
part of a neuropsychological examination is to name as many words beginning with a
particular letter as the patient can in one minute. Patients who abuse cocaine often have
difficulty completing tasks, such as the one described, that require concentration and
memory.

4.4.1 Differential Diagnosis of Substance Induced Psychotic

Disorder and Medicine Induced Psychotic Disorders
A diagnosis of Substance-Induced Psychotic Disorder should be made instead of a
diagnosis of Substance Intoxication or Substance Withdrawal only when
1) The psychotic symptoms are judged to be in excess of those usually associated
with the intoxication or withdrawal syndrome.
2) When the symptoms are sufficiently severe to warrant independent clinical attention.
3) Individuals intoxicated with stimulants, cannabis, the opioid meperidine, or
phencyclidine, or those withdrawing from alcohol or sedatives, may experience
altered perceptions (scintillating lights, sounds, visual illusions) that they recognise
as drug effects.
4) If reality testing for these experiences remains intact (i.e., the person recognises
that the perception is substance induced and neither believes in nor acts on it),
then the diagnosis is not Substance-Induced Psychotic Disorder.
5) Instead, Substance Intoxication or Withdrawal, With Perceptual
Disturbances, is diagnosed (e.g., Cocaine Intoxication, With Perceptual
Disturbances).
6) “Flashback” hallucinations that can occur long after the use of hallucinogens has
stopped are diagnosed as Hallucinogen Persisting Perception Disorder.
7) Moreover, if substance-induced psychotic symptoms occur exclusively during the
course of a delirium, as in some severe forms of Alcohol Withdrawal, the psychotic
symptoms are considered to be an associated feature of the delirium and are not
diagnosed separately.
8) A Substance-Induced Psychotic Disorder is distinguished from a primary
Psychotic Disorder by the fact that a substance is judged to be etiologically
related to the symptoms.
9) A Substance-Induced Psychotic Disorder due to a prescribed treatment for a
mental or general medical condition must have its onset while the person is receiving
the medication (or during withdrawal, if there is a withdrawal syndrome associated
with the medication).
10) Once the treatment is discontinued, the psychotic symptoms will usually remit
within days to several weeks (depending on the half-life of the substance and the
presence of a withdrawal syndrome). If symptoms persist beyond 4 weeks, other
causes for the psychotic symptoms should be considered.
11) Because individuals with general medical conditions often take medications for
67
Schizophrenia and Other those conditions, the clinician must consider the possibility that the psychotic
Psychotic Disorders
symptoms are caused by the physiological consequences of the general medical
condition rather than the medication, in which case Psychotic Disorder Due to a
General Medical Condition is diagnosed.
12) The history often provides the primary basis for such a judgment. At times, a
change in the treatment for the general medical condition (e.g., medication
substitution or discontinuation) may be needed to determine empirically for that
person whether the medication is the causative agent.
13) If the clinician has ascertained that the disturbance is due to both a general medical
condition and substance use, both diagnoses (i.e., Psychotic Disorder Due to a
General Medical Condition and Substance-Induced Psychotic Disorder may be
given.
14) When there is insufficient evidence to determine whether the psychotic symptoms
are due to a substance (including a medication) or to a general medical condition
or are primary (i.e., not due to either a substance or a general medical condition),
Psychotic Disorder Not Otherwise Specified would be indicated.
Specify if:
With Onset During Intoxication: if criteria are met for Intoxication with the substance
and the symptoms develop during the intoxication syndrome
With Onset During Withdrawal: if criteria are met for Withdrawal from the substance
and the symptoms develop during, or shortly after, a withdrawal syndrome
Self Assessment Questions
1) What are the subtypes and specifiers? Discuss.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) What are the methods used in diagnosing the substance induced psychotic
disorders?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) Differentiate between substance induced and medicine induced psychotic
disorders.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

68 .....................................................................................................................
 Substance Induced
4.5 TREATMENTS Psychotic Disorder

Treatment is determined by the underlying cause and severity of psychotic symptoms.

However, treatment of a substance-induced psychotic disorder is often similar to treatment
for a primary psychotic disorder such as schizophrenia. Appropriate treatments may
include psychiatric hospitalisation and antipsychotic medication.
Treatment is determined by the underlying cause and severity of psychotic symptoms.
However, treatment of a substance-induced psychotic disorder is often similar to treatment
for a primary psychotic disorder such as schizophrenia. Appropriate treatments may
include psychiatric hospitalisation and antipsychotic medication.

4.5.1 Hospitalisation
Hospitalisation or inpatient care is the most restrictive form of treatment for a psychiatric
disorder, addictive disorder, or for someone with more than one diagnosis . Whether it
is voluntary or involuntary, the patient relinquishes the freedom to move about and,
once admitted, becomes subject to the rules and schedule of a treatment environment.
Patients who are likely to require hospitalisation include especially if the patient is
delirious, suicidal, homicidal, or gravely disabled. As inpatients, they may require the
administration of medications (e.g, haloperidol, risperidone, carbamazepine) to relieve
any psychosis related to the chemicals inhaled.
Hospitalisation is necessary in cases where an individual is in imminent danger of harming
himself or others or has made a suicide attempt. Crisis stabilization, behaviour
modification , supervised substance abuse detoxification , and medication management
are compelling reasons to consider hospitalisation. Ideally, hospitalisation is at one end
of a comprehensive continuum of services for people needing treatment for behavioural
problems. It is generally viewed as a last resort after other less restrictive forms of
treatment have failed.
Treatment may vary depending on the drug involved. Hallucinogen and phencyclidine
psychosis may not respond well to antipsychotics. A supportive approach is preferred,
with reassuring, structured, and protective surroundings. Agitation may be best treated
with short-acting benzodiazepines.

4.5.2 Medical Care

The medical care of patients with inhalant-related psychiatric disorders encompasses
many areas.
A team of medical professionals must work in unison to ensure that every aspect of the
treatment plan is fulfilled.

4.5.3 Counselling
The goals of substance abuse counseling are:
1) Achieving and maintaining abstinence from alcohol or other drugs of abuse or, for
patients unable or unwilling to work toward total abstinence, reducing the amount
and frequency of use and concomitant biopsychosocial sequelae associated with
drug use disorders.
2) Stabilizing acute psychiatric symptoms.
3) Resolving or reducing problems and improving physical, emotional, social, family,
interpersonal, occupational, academic, spiritual, financial, and legal functioning. 69
Schizophrenia and Other 4) Working toward positive lifestyle change.
Psychotic Disorders
5) Early intervention in the process of relapse to either the addiction or the psychiatric
disorder.
Counseling (supportive therapy) should be initiated, along with patient education to
explain the dangers of huffing. Evaluate patients for psychiatric comorbidity.
Interventions include the following:
1) Motivating patients to seek detoxification or inpatient treatment if symptoms
warrant, and sometimes facilitating an involuntary commitment for psychiatric care.
2) Educating patients about psychiatric illness, addictive illness, treatment, and the
recovery process.
3) Supporting patients’ efforts at recovery and providing a sense of hope regarding
positive change.
4) Referring patients for other needed services (case management, medical, social,
vocational, economic needs).
5) Helping patients increase self awareness so that information regarding dual disorders
can be personalised.
6) Helping patients identify problems and areas of change.
7) Helping patients develop and improve problem solving ability and develop recovery
coping skills.
8) Facilitating pharmacotherapy evaluation and compliance. (This requires close
collaboration with the team psychiatrist.)
Change in the addicitive behaviour may occur as a result of the patient counselor
relationship and the team relationship (i.e., counselor, psychiatrist, psychologist, nurse,
or other professionals such as case manager or family therapist). A positive therapeutic
alliance is seen as critical in helping patients become involved and stay involved in the
recovery process. Community support systems, professional treatment groups, and
self-help programs also serve as possible agents of positive change. For the more
chronically and persistently mentally ill patients, a case manager may also function as an
important agent in the change process.
Although patients have to work on a number of intrapersonal and interpersonal issues
as part of long term recovery, medications can facilitate this process by attenuating
acute symptoms, improving mood, or improving cognitive abilities or impulse control.
Thus, medications may eliminate or reduce symptoms as well as help patients become
more able to address problems during counseling sessions. A severely depressed patient
may be unable to focus on learning cognitive or behavioural interventions until he or she
experiences a certain degree of remission from symptoms of depression. A floridly
psychotic patient will not be able to focus on abstinence from drugs until the psychotic
symptoms are under control.
No controlled studies have been performed to guide the treatment of patients who
abuse inhalants and who have inhalant dependence. Additionally, no specific medications
indicated by the pharmaceutical industry are available for detoxification from inhalants.
Programs are available that specifically treat inhalant abuse; however, they are rare and
70 difficult to find. Therefore, treatment planning most often is tailored much like that of the
treatment of patients with chemical dependence, in which the first step is to detoxify the Substance Induced
Psychotic Disorder
patient.
Patients who are addicted to inhalants experience withdrawal symptoms similar to those
of any other patient addicted to drugs, including tremors, chills, sweats, cramps, nausea,
and hallucinations.
Next, a peer system is established.
Once these 2 tasks are accomplished, assess the patient for physical, cognitive, and
neurologic problems. If any problems are noted in these areas, they must be treated
immediately. Identify any strengths the patient has and build on these strengths to increase
them and to create new additional strengths for the patient. Address any other problems
they may have. The goals are to return the patient to the community with a drug-free
peer network and to continue or enhance self-support.
Treat any conduct problems noted.
Once the patient is detoxified, evaluate for other psychiatric illnesses using the DSM-
IV-TR.
The patient should participate in group therapy sessions, 12-step programs/chemical
dependency groups, rational-emotive therapy, cognitive behaviour therapy, and family
therapy.
Discuss safe sex with the patient, including partner precautions and birth control. In
addition, the family should receive education about the disorder, secure substances that
could be huffed, and become familiar with local mental health laws regarding commitment
policies.
No medications should be used unless a treatable DSM-IV-TR diagnosis has been
identified.
If the patient has depression independent of the inhalant abuse, treat with the
antidepressant of choice.
If the patient abuses alcohol in addition to inhalants, disulfiram (Antabuse) or naltrexone
can be used in appropriate settings.
If the patient meets DSM-IV-TR criteria for attention-deficit/hyperactivity disorder, a
psychostimulant such as pemoline (Cylert) can be used for treatment. The United States
Food and Drug Administration (FDA) concluded that the overall risk of liver toxicity
from pemoline outweighs the benefits. In May 2005, Abbott chose to stop sales and
marketing of their brand of pemoline (Cylert) in the United States. In October 2005, all
companies that produced generic versions of pemoline also agreed to stop sales and
marketing of pemoline.
If the patient is psychotic as a result of the inhalant abuse (inhalant-induced psychosis),
the physician may use an appropriate antipsychotic such as haloperidol (Haldol) or
risperidone (Risperdal), with or without a benzodiazepine. This is the physician’s choice.
If the patient has an inhalant-induced mood disorder, detoxification is recommended,
without the use of any medications unless the depression persists for longer than 2-4
weeks after withdrawal.

4.5.4 Detoxification
Detoxification is also recommended for patients who are experiencing inhalant-induced 71
Schizophrenia and Other anxiety; however, the use of sedatives or antianxiety medications is contraindicated
Psychotic Disorders
because inhalant intoxication can worsen if the patient uses again.
If the patient cannot maintain sobriety, the physician should consider residential treatment
options, which can last anywhere from 3-12 months.
Most persons who abuse inhalants receive most of their medical care in local emergency
departments after they have either passed out or become psychotic from chemical
inhalation. In the emergency department, they receive supportive care, social
interventions, and appropriate medical care.

4.5.5 Surgical Care

Patients may need liver or kidney transplantation.
Consultations
Chemical dependence counselor
Attorney, if legal problems develop
Social worker
Family therapist
Peer-group therapist
Dietitian (possibly)
Diet
Consultation with a dietitian may be helpful if patients have poor nutrition (eg, liver
problems, low protein).
If no additional medical problems are present, patients can eat a regular diet.
Activity
Maintain sobriety.
Patients who are not a danger to themselves or others, are not gravely disabled, and
are medically stable can maintain routine activities.

4.5.6 Medications
If psychosis or delirium is present, use an antipsychotic such as risperidone or haloperidol
and/or an anticonvulsant such as carbamazepine. Avoid benzodiazepines because they
may worsen respiratory depression.
Antipsychotics
Reduce psychosis and aggressive behaviour. All antipsychotics may be equally
efficacious, but their adverse effect profiles are different. The atypical antipsychotics
such as risperidone, olanzapine, quetiapine, and ziprasidone have an advantage in the
adverse effect profile, especially with their lower risk to cause adverse extrapyramidal
effects and tardive dyskinesia.

4.5.7 Prognosis
Psychotic symptoms induced by substance intoxication usually subside once the
72 substance is eliminated. Symptoms persist depending on the half-life of the substances
(i.e., how long it takes the before the substance is no longer present in an individual’s Substance Induced
Psychotic Disorder
system). Symptoms, therefore, can persist for hours, days, or weeks after a substance
is last used.

4.5.8 Prevention
There is very little documented regarding prevention of substance-induced psychotic
disorder. However, abstaining from drugs and alcohol or using these substances only in
moderation would clearly reduce the risk of developing this disorder. In addition, taking
medication under the supervision of an appropriately trained physician should reduce
the likelihood of a medication induced psychotic disorder. Finally, reducing one’s
exposure to toxins would reduce the risk of toxin-induced psychotic disorder.
Self Assessment Questions
1) Discuss the various treatment approaches to substance induced psychotic disorder.
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2) Discuss hospitalisation and medical care as important methods of treatment of
this disorder.
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3) What is the prognosis of this disorder?
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4) How do we prevent this substance induced psychotic disorder from manifesting?
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4.6 LET US SUM UP

Substance-Induced Psychotic Disorders may at times not resolve promptly when the
offending agent is removed. Agents such as amphetamines, phencyclidine, and cocaine
have been reported to evoke temporary psychotic states that can sometimes persist for
73
weeks or longer despite removal of the agent and treatment with neuroleptic medication.
Schizophrenia and Other These may be initially difficult to distinguish from non-substance-induced Psychotic
Psychotic Disorders
Disorders.
The essential features of Substance-Induced Psychotic Disorder are prominent
hallucinations or delusions that are judged to be due to the direct physiological effects
of a substance (i.e., a drug of abuse, a medication, or toxin exposure. Hallucinations
that the individual realises are substance induced are not included here and instead
would be diagnosed as Substance Intoxication or Substance Withdrawal with the
accompanying specifier.
With Perceptual Disturbances. The disturbance must not be better accounted for by a
Psychotic Disorder that is not substance induced The diagnosis is not made if the
psychotic symptoms occur only during the course of a delirium. This diagnosis should
be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal
only when the psychotic symptoms are in excess of those usually associated with the
intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to
warrant independent clinical attention.
A Substance-Induced Psychotic Disorder is distinguished from a primary Psychotic
Disorder by considering the onset, course, and other factors. For drugs of abuse, there
must be evidence from the history, physical examination, or laboratory findings of
Dependence, Abuse, intoxication, or withdrawal.
Substance Induced Psychotic Disorders arise only in association with intoxication or
withdrawal states but can persist for weeks, whereas primary Psychotic Disorders may
precede the onset of substance use or may occur during times of sustained abstinence.
Once initiated, the psychotic symptoms may continue as long as the substance use
continues.
Another consideration is the presence of features that are atypical of a primary Psychotic
Disorder (e.g., atypical age at onset or course). For example, the appearance of delusions
de novo in a person over age 35 years without a known history of a primary Psychotic
Disorder should alert the clinician to the possibility of a Substance-Induced Psychotic
Disorder. Even a prior history of a primary Psychotic Disorder does not rule out the
possibility of a Substance-Induced Psychotic Disorder.
It has been suggested that 9 out of 10 nonauditory hallucinations are the product of a
Substance-Induced Psychotic Disorder or a Psychotic Disorder Due to a General
Medical Condition. In contrast, factors that suggest that the psychotic symptoms are
better accounted for by a primary Psychotic Disorder include persistence of psychotic
symptoms for a substantial period of time (i.e., a month or more) after the end of
Substance Intoxication or acute Substance Withdrawal; the development of symptoms
that are substantially in excess of what would be expected given the type or amount of
the substance used or the duration of use; or a history of prior recurrent primary Psychotic
Disorders.
Other causes of psychotic symptoms must be considered even in a person with
Intoxication or Withdrawal, because substance use problems are not uncommon among
persons with (presumably)non-substance induced Psychotic Disorders. Psychotic
symptoms induced by substance intoxication usually subside once the substance is
eliminated. Symptoms persist depending on the half-life of the substances (i.e., how
long it takes the before the substance is no longer present in an individual’s system).
Symptoms, therefore, can persist for hours, days, or weeks after a substance is last
used. There is very little documented regarding prevention of substance-induced
74 psychotic disorder. However, abstaining from drugs and alcohol or using these substances
only in moderation would clearly reduce the risk of developing this disorder. In addition, Substance Induced
Psychotic Disorder
taking medication under the supervision of an appropriately trained physician should
reduce the likelihood of a medicationinduced psychotic disorder. Finally, reducing one’s
exposure to toxins would reduce the risk of toxin-induced psychotic disorder.

4.7 UNIT END QUESTIONS

1) Define and describe substance induced psychotic disorders.
2) Discuss how substance induced disorder can be caused?
3) Define subtypes of substance induced psychotic disorder?
4) What are the causes of these disorders?
5) Discuss critically the various treatments available for this disorder.

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2000.
Kaplan, Harold I., M.D., and Benjamin J. Sadock, M.D. Kaplan and Sadock’s
Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry. 8th edition.
Baltimore: Williams and Wilkins, 2002.
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