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CBT helps patients with schizophrenia to gain some insight into their illness and
appears to be effective in reducing the severity of symptoms and decreasing the risk of relapse.
DBT combines cognitive and behavioral theories. Patients with schizophrenia may
benefit from DBT to improve interpersonal skills.
Individual psychotherapy focuses on forming a therapeutic alliance between thera-
pists and patients with schizophrenia. A good therapeutic alliance is likely to help patients with schizophrenia remain in therapy, increase adherence to treatments, and have positive outcomes at 2-year follow-up evaluations.
Personal therapy, a recently developed form of individual treatment, uses social
skills and relaxation exercises, self-reflection, self-awareness, exploration of vulner- ability and stress, and psychoeducation to enhance personal and social adjustment of patients with schizophrenia. Patients who receive personal therapy have shown better social adjustment and a lower rate of relapse after 3 years than those not receiving it.
Many patients with schizophrenia benefit from art therapy because it helps them
communicate with and share their inner world with others.
Employment programs that include individualized job development, rapid place-
ment, ongoing job supports, and integration of mental health and vocational services have been found to be effective in helping patients with schizophrenia to achieve employment.
Family-oriented therapies that help family and patients with schizophrenia under-
stand the disorder and encourage discussions of psychotic episodes and events leading up to them may be effective in reducing relapses.
Treat patients for co-occurring substance abuse. Substance abuse is the most com-
mon co-occurring disorder in patients with schizophrenia. Integrated treatment programs for schizophrenia and substance use produce better outcomes.
Many studies show that integrating psychosocial and medication treatment pro-
duces the best results in patients with schizophrenia.
Recurrence Rate
The reported recurrence rates range from 10% to 60%; approximately 20% to 30% of patients with schizophrenia can have somewhat normal lives, 20% to 30% continue to experience moderate symptoms, and 40% to 60% of them remain significantly impaired for their entire lives.
PATIENT EDUCATION
Information regarding schizophrenia is available from the National Institutes for
Mental Health website at http://www.nimh.nih.gov/health/ publications/schizo- phrenia/index.shtml.
Antipsychotic medications can produce dangerous side effects when taken with
certain drugs. It is important for patients to tell health care providers about all medications, including over-the-counter medications, prescribed medications, vitamins, minerals, and herbal supplements that patients take. Note: Medications should be used with particular caution in children, pregnant/breastfeeding women, and older adults. Note: Black box warnings.
It is important to teach patients about the importance of medication adherence and
to avoid using alcohol and other substances.
For excellent patient education resources, visit eMedicine’s Mental Health and
Behavior Center. See also eMedicine’s patient education article on schizophrenia.
SCHIzOPHRENIfORM DISORDER 135
MEDICAl/lEGAl PITfAllS Misdiagnosis
Patients with schizophrenia are addicted to nicotine at three times the rate of the
general population (75%–90% vs. 25%–30%).
Approximately, 20% to 70% of patients with schizophrenia have a comorbid
substance abuse problem, which is associated with increased violence, suicidality, nonadherence with treatment, hostility, crime, poor nutrition, and so forth.
Mental health providers should inform patients being treated with conventional
antipsychotic medications about the risk of TD. AIMS (Abnormal Involuntary Movement Scale) is recommended for detecting TD early.
Patients with schizophrenia are found to have a higher risk for acquiring obesity, dia-
betes, cardiovascular disease, HIV, lung diseases, and rheumatoid arthritis. It is impor- tant for mental health care providers to monitor their physical conditions regularly.
Schizophreniform Disorder
BACKGROUND INfORMATION Definition of Disorder
This is characterized by the presence of the principal symptoms of schizophrenia,
including delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms.
An episode of the disorder (including prodromal, active, and residual phases) lasts
at least 1 month but less than 6 months.
Etiology
The cause of schizophreniform disorder remains unknown.
Current biological and epidemiological data suggest that some of the schizophreni-
form patients are similar to those with schizophrenia, whereas others have a disor- der similar to mood disorder.
Demographics
The lifetime prevalence rate of schizophreniform is 0.2%, and a 1-year prevalence
rate is 0.1%.
Risk factors Age
Schizophreniform disorder is most common in adolescents and young adults.
Gender
The prevalence of schizophreniform disorder is equally distributed between men
and women, with peak onset between the ages of 18 and 24 years in men and 24 and 35 years in women.
Family History
Studies show that relatives of individuals with schizophreniform disorder are
at higher risk of having mood disorders than are relatives of individuals with schizophrenia.
Relatives of individuals with schizophreniform disorder are more likely to
have a psychotic mood disorder than are relatives of individuals with bipolar disorders.
DIAGNOSIS
Differential Diagnosis Schizophrenia
Brief psychotic disorder
Substance-induced psychotic disorder
Bipolar disorder and major depression with mood-incongruent features
ICD-10 Codes
Sohizophreniform Disorder (F20.81) Diagnostic Workup
Medical Medications (i.e., Steroids) Physical and mental status examination
Electrolytes (potassium, chloride, and bicarbonate)
Thyroid function tests (TSH, T3, and T4)
Screen for alcohol and drugs, including amphetamines, methamphetamines,
barbiturates, phenobarbital, benzodiazepines, cannabis, cocaine, codeine, cotinine, morphine, heroin, lysergic acid diethylamide (LSD), methadone, and PCP.
Initial Assessment
Current physical status and physical history
Current mental status and mental health history, including symptoms patient expe-
riences, how long patient has been having symptoms, when the symptoms started, how often the symptoms occur, when and where symptoms tend to occur, how long symptoms last, and what effect symptoms have on patient’s ability to function Drug history, including prescribed and over-the-counter drugs
Safety needs
Clinical Presentation: Symptoms
Delusions (somatic, ideas of reference, thought broadcasting, thought insertion, and
thought withdrawal)
Hallucinations (visual, auditory, tactile, olfactory, and gustatory)
Disorganized speech (e.g., frequent derailment or incoherence)
Grossly disorganized or catatonic behavior
Negative symptoms (e.g., flat affect, lack of energy and initiative)
DSM-5 Diagnostic Guidelines
(a) Acute presentation of psychotic symptoms (2 weeks or less from a nonpsychotic to a clearly psychotic state); (b) symptoms present for the majority of the time since the establishment of an obviously psychotic clinical picture; and (c) acute polymorphic psychotic disorder ruled out.
Note: If the schizophrenic symptoms last for more than 1 month, the diagnosis should be changed to schizophrenia.
SCHIzOPHRENIfORM DISORDER 137
TREATMENT OvERvIEW
Acute Treatment
Inpatient treatment is often necessary for patients with schizophreniform disorder
for effective assessment and treatment. Patients who are at risk of harming them- selves or others require hospitalization to allow comprehensive evaluation and to ensure their safety as well as others.
The pharmacotherapy for schizophreniform disorder is similar to that for schizo-
phrenia. Atypical (second generation) antipsychotics are mostly used at this time.
See details in the schizophrenia discussion.
Antidepressants may help reduce mood disturbances associated with schizophreni-
form disorder, but patients need to be monitored carefully for possible exacerba- tions of psychotic symptoms.
Chronic Treatment
Long-acting medications are found to increase treatment adherence, including
paliperidone (Invega Sustenna), a major active metabolite of risperidone (Risperdal Consta) and the first oral agent allowing once-daily dosing (6 mg PO in the
morning).
Ziprasidone (Geodon) and aripiprazole (Abilify) are available in injection form to
help control acute psychotic symptoms. It is dose dependent and all second-gen- eration antipsychotics (APS) are more likely to cause extrapyramidal symptoms extrapyramidal symptoms (EPS) for patients who are not antipsychotic-naive.
Long-acting agents are made with aqueous vehicles—different from the typical
injections that are sesame oil–based and can cause scarring and discomfort.
It is critical to monitor and manage side effects of antipsychotic medications (e.g.,
extrapyramidal side effects, TD, sedation, postural hypotension, weight gain, dis- turbances in sexual function). See details in the schizophrenia section.
Psychotherapeutic treatment modalities used in the treatment of patients with
schizophrenia may be helpful in treating patients with schizophreniform disorder.