Schizophrenia Sometimes called split personality disorder. Achronic, severe, and disabling mental illness.

s. It affects men and women with equal frequency. People who have it may hear voices, see things that aren't 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 and delusions. For women, they start in the mid-20s to early 30s. No one is sure what causes schizophrenia, but your genetic makeup and brain chemistry probably play a role. Symptoms: Unusual thoughts or perceptions Disorders of movement Difficulty speaking and expressing emotion Problems with attention, memory and organization Risk Factors: Family history of Schizophrenia Drug abuse Shyness Emotional sensitivity Unsociability Lack of emotion Loners

Different types of Schizophrenia Paranoid schizophrenia: The individual is preoccupied with one or more delusions or many auditory hallucinations but does not have symptoms of disorganized schizophrenia. Disorganized schizophrenia: Prominent symptoms are disorganized speech and behavior, as well as flat or inappropriate affect. The person does not have enough symptoms to be characterized as catatonic schizophrenic. Catatonic schizophrenia: The person with this type of schizophrenia primarily has at least two of the following symptoms: difficulty moving, resistance to moving, excessive movement, abnormal movements, and/or repeating what others say or do. Undifferentiated schizophrenia: This is characterized by episodes of two or more of the following symptoms: delusions, hallucinations, disorganized speech or behavior, catatonic behavior or negative symptoms, but the individual does not qualify for a diagnosis of paranoid, disorganized, or catatonic type of schizophrenia. Residual schizophrenia: While the full-blown characteristic positive symptoms of schizophrenia (those that involve an excess of normal behavior, such as delusions, paranoia, or heightened sensitivity) are absent, the sufferer has less severe forms of the disorder or has only negative symptoms (symptoms characterized by a decrease in function, such as withdrawal, disinterest, and not

1. 2. 3. 4. 5.

Mental health professionals use the following criteria to diagnose schizophrenia: The presence of two or more of the following symptoms for at least 30 days: Hallucinations Delusions Disorganized speech Disorganized or catatonic behavior Negative symptoms (emotional flatness, apathy, lack of speech)

- Significant problems functioning at work or school, relating to other people, and taking care of oneself. - Continuous signs of schizophrenia for at least 6 months, with active symptoms (hallucinations, delusions, etc.) for at least 1 month. - No other mental health disorder, medical issue, or substance abuse problem is causing the symptoms. Medications: 1) Antipsychotic medications Trifluoperazine(Stelazine) Chlorpromazine(Thorazine) Fluphenazine(Prolixin) Haloperidol(Haldol) Loxapine(Loxitane) Perphenazine(Trilafon) Thioridazine(Mellaril)

2)

Atypical medications Ziprasidone(Geodon) Aripiprazole(Abilify) Clozapine(Clozaril) Olanzapine(Zyprexa) Quetiapine(Seroquel) Risperidone(Risperdal)

Other treatment options include: Electroconvulsive ("shock") therapy Psychotherapy Family support Rehabilitation NURSING INTERVENTIONS: Strengthening differentiation Provide patient with honest and consistent feedback in a non threatening manner. Avoid challenging the content of patients behavior Focus interactions on patients behavior. Administer drugs as prescribed while monitoring and documenting patients response to drug regimen. Use simple and clear language when speaking with the patient. Explain all procedures, test and activities to patient before starting them

Promoting socialization Encourage patient to talk about feelings in the context of a trusting, supportive relationship. Allow patient to reveal delusions to you without engaging in power struggle over the content or the entire reality of the delusions. Use supportive, emphatic approach to focus on patients feelings about troubling events or conflicts. Provide opportunities for socialization and encourage participation in group activities. Be aware of personal space and use touch judiciously. Help patient to identify behaviors that alienate significant others and family members. Ensuring safety: Monitor patient for behaviors that indicate increased anxiety and agitation. Collaborate with patient to identify anxious behaviors as well as causes. Establish consistent limits on patients behavior and clearly communicate these limits to patients, family member, and health care providers. Secure all potential weapons and articles from patients room and the unit environment that could be used to inflict injury. Determine the need for external control, including seclusion or restraints. Communicate the decision to patient and put plan into action. Frequently monitor the patient within guidelines of facilitys policy on restrictive devices and assess the patients level of agitation.

Schizophreniform Disorder Schizophreniform disorder is characterized by the presence of the Criterion A symptoms of schizophrenia, including delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms. The disorder, including its prodromal, active, and residual phases, lasts longer than 1 month but less than 6 months. Diagnostic features In order to establish the diagnosis of schizophreniform disorder, theDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IVTR),states that at least 2 of the following signs must be present, each for a significant length of time during a 1-month period (or less, if successfully treated). Delusions/hallucinations Disorganized speech (eg, frequent derailment, incoherence) Grossly disorganized or catatonic negative behavior symptoms, ie, affective flattening, alogia, or avolition Only one Criterion A symptom is required if delusions are bizarre, if hallucinations consist of a voice that is keeping up a running commentary on the person's behavior or thoughts, or if 2 or more voices are conversing with each other. An episode of the disorder (including prodromal, active, and residual phases) must last at least 1 month but less than 6 months. If the diagnosis must be made

Specify if the patient is without good prognostic features, defined as 2 or more of the following: Onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning Perplexity and thought disorganization at the height of the psychotic episode Good premorbid social and occupational functioning Absence of blunted or flat affect Diagnosis and Differential Diagnosis Distinguishing schizophreniform disorder from other medical and psychiatric conditions that may present in a floridly psychotic state can be challenging. A detailed history should focus on the following: Time of symptom onset Course Premorbid functioning Precipitants Physical health Use of medications Use of alcohol and other substances Family history Previous episodes (if any)

Treatment In general, treatment aims to protect and stabilize the patient, to minimize the psychosocial consequences, and to resolve the target symptoms with minimal adverse effects. The patient who may be at risk of harming himself or herself or others requires hospitalization. This allows for complete diagnostic evaluation and helps to ensure the safety of the patient and others. A supportive environment with minimal stimulation is most helpful. As improvement progresses, help with coping skills, problem-solving techniques, and psychoeducational approaches may be added for patients and their families. Patients may benefit from a structured intermediate environment, such as a day hospital, during the initial phases of returning to the community. Psychotherapy Virtually all psychotherapeutic treatment modalities used in the treatment of patients with schizophrenia may be helpful in treating patients with schizophreniform disorder. Insight-oriented therapy is not indicated in patients with schizophreniform disorder because they have limited ability to explore, and they may also be in denial. Patients may experience a high degree of distress related to the onset of symptoms. Both supportive and educational approaches may help patients to manage feelings of turmoil or distress. Group psychotherapy may be helpful; however, patients with schizophreniform disorder who are concerned about their prognosis may become frightened in groups in which they are mixed with patients who have chronic schizophrenia. Thus, care must be taken when forming therapy groups.

Family and social-vocational therapies The treatment of patients with schizophreniform disorder frequently involves working with family members and significant others. The family therapy strategies used in working with the families of patients with schizophrenia are highly appropriate for patients with schizophreniform disorder and their families. In light of the variable course of schizophreniform disorder, brief treatment strategies with clear goals may initially be helpful, although treatment strategies must be flexible to allow for the transition to longer-term treatments for patients who progress to schizophrenia. Similarly, social-vocational function may be preserved in patients with schizophreniform disorder. However, in patients exhibiting impairments in these areas, rehabilitative strategies similar to those described for patients with schizophrenia are appropriate. Pharmacotherapy At this time, atypical antipsychotics, such as risperidone, olanzapine, quetiapine, and ziprasidone, are commonly used. In November 2003, a new atypical antipsychotic drug, aripiprazole (Abilify), was approved by the US Food and Drug Administration. Aripiprazole has a novel mechanism of action because it is a partial agonist at the dopamine receptors, unlike its predecessors. Patient and family education Efforts should be made to educate both the patients and their families about the early signs of relapse and the need for continuing treatment. Those approaches advance the overall aim of helping patients regain productive roles in society while reducing the risk of relapse. Families with a high degree of emotional expression are likely to cause additional stress to the patient and to increase the likelihood of relapse. The patient's condition, the patient's family, and the

Schizoaffective Disorder The term schizoaffective disorder was coined by Dr. Jacob Kasanin in 1933. Schizoaffective disorder is a perplexing mental illness distinguished by a combination of symptoms of a thought disorder or other psychotic symptoms such as hallucinations or delusions (schizophrenia component) and those of a mood disorder (depressive or manic component). The coupling of symptoms from these divergent spectrums makes treating patients who are schizoaffective difficult. History Diagnostic criteria for schizoaffective disorder are as follows: An uninterrupted period of illness occurs during which a major depressive episode, a manic episode, or a mixed episode occurs with symptoms that meet criterion A for schizophrenia. The major depressive episode must include criterion A1, ie, depressed mood. During the same period of illness, delusions or hallucinations occur for at least 2 weeks, in the absence of prominent mood symptoms. Symptoms that meet the criteria for mood episodes are present for a substantial portion of the total active and residual periods of illness. The disturbance is not due to the direct physiologic effects of a substance (eg, illicit drugs, medications) or a general medical condition. The bipolar type is diagnosed if the disturbance includes a manic or a mixed episode (or a manic or a mixed episode and major depressive episodes). The depressive type is diagnosed if the disturbance includes only major

Physical Obtain a complete medical history, and perform a complete mental status examination, physical examination, and neurologic examination to assist with the evaluation and rule out other disease processes. Although the mental status examination varies for each patient, examples of items to assess are listed below. Because of the variability of the presentation of the disorder, any or all symptoms of schizophrenia, bipolar disorder, or major depressive disorder may manifest depending on the presenting subtype. Appearance - Ranges from well-groomed to disheveled Eye contact - Appropriate, increased, or decreased Facial expression - Neutral, angry, euphoric, sad Motor - Possible psychomotor agitation or retardation Cooperativeness - May cooperate or may be uncooperative Mood - Euthymic, depressed, or manic Affect - Ranges from appropriate to flat Speech - Ranges from poverty to flight of ideas or pressured Suicidal ideation - May or may not be present. Remember that individuals with this disorder have a lifetime risk for suicide, which is significant. Inquiring about suicidal ideation at each visit is always important. In addition, the interviewer should inquire about past acts of self-harm or violence. Ask the following types of questions when determining suicidal ideation or intent. "Do you have any thoughts of wanting to harm or kill yourself?""Do you have any thoughts that you would be better off dead?" If the reply is positive for these thoughts, inquire about specific plans, suicide notes, family history (anniversary reaction), and impulse control. Also, ask how the patient views

 Homicidal ideation - May or may not be present. Inquiring about homicidal ideation or intent during each patient interview is also important. Ask the following types of questions to help determine homicidal ideation or intent. "Do you have any thoughts of wanting to hurt anyone?" "Do you have any feelings or thoughts that you wish someone were dead?" If the reply to one of these questions is positive, ask the patient if he or she has any specific plans to injure someone and how he or she plans to control these feelings if they occur again. Orientation - To elicit responses concerning orientation (ie, person, place, time, situation), ask the patient questions, as follows. "What is your full name?" "Do you know where you are?" "What is the month, date, year, day of the week, and time?" "Do you know why you are here?" Consciousness - Levels of consciousness are determined by the interviewer and are rated as (1) coma, characterized by unresponsiveness; (2) stuporous, characterized by response to pain; (3) lethargic, characterized by drowsiness; and (4) alert, characterized by full awareness. Concentration and attention - Ask the patient to subtract 7 from 100, then to repeat the task from that response. This is known asserial 7s. Next, ask the patient to spell the wordworldforward and backward. Reading and writing - Ask the patient to write a simple sentence (noun/verb). Then, ask patient to read a sentence (eg, "Close your eyes."). The part of the MMSE evaluates the patient's ability to sequence. Memory - To evaluate a patient's memory, have him or her respond to the following prompts. For remote memory, "What was the name of your first grade teacher?" For recent memory, "What did you eat for dinner last night?" For immediate memory, "Repeat these 3 words: pen, chair, flag." Tell the

 Delusions - Any type possible (eg, paranoid, thought insertion or withdrawal, grandiose, bizarre, to name a few) Hallucinations - Any type possible (most common is auditory, least common is gustatory) Insight - Range varies Judgment - Range varies Causes Although the cause of schizoaffective disorder is unknown, the cause may be similar to schizophrenia nature versus nurture. To date, no specific genetic markers have been identified. Environmental causes of malnutrition, viral infections, or complication at birth may play a role. Finally, abnormalities of the neurotransmitters serotonin, norepinephrine, and/or dopamine could all have a role in this disorder. More research is needed to fully elucidate the causes of schizoaffective disorder. Treatment If patients are suicidal, homicidal, or gravely disabled, admit them to an inpatient psychiatric unit. Inpatient treatment is mandatory for patients who are dangerous to themselves or others and for patients who cannot take care of themselves. Patients who have schizoaffective disorder can greatly benefit from psychotherapy and well as psychoeducational programs. They should receive therapy that involves their families, develops their social skills, and focuses on cognitive rehabilitation.

Treatment includes education about the disorder and its treatment, family assistance in compliance with medications and appointments, and maintenance of structured daily activities (ie, schedule of daily events) for the patient. Family involvement is needed in the treatment of this particular disorder. Family education is particularly important in this disorder secondary to the various mood and psychotic states. Families need information regarding patient's mediations and the dynamic nature of this illness.

Activity Restrict activity if patients represent a danger to themselves or to others or if they are gravely disabled. Otherwise, encourage patients who are schizoaffective to continue their normal routines and strengthen their social skills whenever possible. Medication Several medications are used to treat schizoaffective disorder. Agent selection depends on whether the depressive or manic subtype is present. Early treatment with medication along with good premorbid function often improves outcomes. In the depressive subtype, combinations of antidepressants (eg, sertraline, fluoxetine) plus an antipsychotic (eg, haloperidol, risperidone, olanzapine, aripiprazole, ziprasidone) are used. In refractory cases, clozapine has been used as an antipsychotic agent. In the manic subtype, combinations of mood stabilizers (eg, lithium, carbamazepine, divalproex) plus an antipsychotic are used.

Delusional Disorder Delusional disorder is an illness characterized by the presence of nonbizarre delusions in the absence of other mood or psychotic symptoms, according to theDiagnostic Manual of Mental Disorders, Fourth Edition, Text Revision (DSMIV-TR).It defines delusions as false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary and these beliefs are not ordinarily accepted by other members of the person's culture or subculture. Non-bizarre refers to the fact that this type of delusion is about situations that could occur in real life, such as being followed, being loved, having an infection, and being deceived by one's spouse. Delusional disorder is on a spectrum between more severe psychosis and overvalued ideas. Bizarre delusions represent the manifestations of more severe types of psychotic illnesses (eg, schizophrenia) and "are clearly implausible, not understandable, and not derived from ordinary life experiences". Current Diagnosis Criteria DSM-IV-TRdefines delusional disorder with the following criteria: A: Nonbizarre delusions (ie, involving situations that occur in real life, such as being followed, poisoned, infected, loved at distance, deceived by spouse or lover, or having a disease) occurring for at least 1 month's duration. B: Criterion A for schizophrenia has never been met (ie, patients do not have simultaneous hallucinations, disorganized speech, negative symptoms such as affective flattening, or grossly disorganized behavior). Note: Tactile and olfactory

C: Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. D: If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E: The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition.

Clinical Features General Approach Theo Manschreckoutlined 3 steps in the initial evaluation of patients who present with delusions. 1. Establish whether pathology is present. This represents a clinical judgment that is sometimes difficult to make. Some comments that appear delusional may be true. In contrast, some reports that initially seem believable may later be identified as delusions as the symptoms worsen, the delusions become less encapsulated (ie, begin to extend to more people or situations), and more information comes to light. The clinical judgment that delusions are present should be made after taking into account the degree of plausibility, systemization, and the possible presence of culturally sanctioned beliefs that are different from one's own beliefs. Making the distinction between a true observation, a firm belief, an overvalued idea, and a delusion is sometimes a challenging task. Often, the extremeness and inappropriateness of the patient's behaviors, rather than the simple truth or falsity of the belief, indicate its delusional nature. 2. The second step is determining the presence or absence of important

3. The third step is to present a systematic differential diagnosis. A thorough history, mental status examination, and laboratory/radiologic evaluation should be performed to rule out other medical and psychiatric conditions that are commonly present with delusions. CNS illness is high on the differential diagnosis of any psychotic disorder, especially so in the onset of delusional disorder in patients older than the typical onset of schizophrenia. Delusional disorder should be seen as a diagnosis of exclusion. Clinical presentation The status examination (including cognitive examination) is usually normal with exception of the presence of abnormal delusional beliefs. In general, patients are well groomed and well dressed without evidence of gross impairment. Speech, psychomotor activity, and eye contact may be affected by the emotional state associated with delusions, but are otherwise normal. Mood and affect are consistent with delusional content; for example, patients with persecutory delusions may be suspicious and anxious. Mild dysphoria may be present without regard of type of delusions. Tactile and olfactory hallucinations may be present and may be prominent if they are related to the delusional theme (eg, the sensation of being infested by insects, the perception of body odor). Systemic or CNS causes of tactile and olfactory hallucinations, such as substance intoxication and withdrawal, and temporal lobe epilepsy, should be ruled out. Auditory or visual hallucinations are characteristic of more severe psychotic disorders (eg, schizophrenia) and should lead away from a diagnosis of delusional disorder.

The thought content is notable for systematized, well-organized, nonbizarre delusions that are possible to occur, such as delusions of being persecuted, being loved by a person of higher status, being infected, having an unfaithful spouse, and others. Delusional concepts may be complex or simple, but bizarre beliefs such as delusions of thought insertion, and thought control are more common in schizophrenia. Contrary to schizophrenia, the thought process is usually not impaired; however, some circumstantiality and idiosyncrasy may be observed, especially in descriptions of the delusional material. Memory and cognition are intact. Level of consciousness is unimpaired. Patients usually have little insight and impaired judgment regarding their pathology. Police, family members, coworkers, and physicians other than psychiatrists are usually the first to suspect the problem and seek psychiatric consultation. Seeking corroborative information, when permitted by the patient, is often crucial. Recall that it is permissible to seek collateral history but that collateral history should not be withheld from the patient. Assessment of homicidal or suicidal ideation is extremely important in evaluating patients with delusional disorder. The presence of homicidal or suicidal thoughts related to delusions should be actively screened for and the risk of carrying out violent plans should be carefully assessed. Reid (2005) pointed out that some types of this illnesserotomanic, jealous, and persecutoryare associated with higher risk for violence than others.History of previous violent acts as well as history of how aggressive feelings were managed in the past may help to assess the risk. Access to weapons should be explored.

Presentation of the subtypes Erotomanic type Related terms include erotomania, psychose passionelle, Clerambault syndrome, and old maid's insanity. The central theme of delusions is that another person, usually of higher status, is in love with the patient. The object of delusion is generally perceived to belong to a higher social class, being married, or otherwise unattainable. Patients with this type of delusion are generally female, although males predominate in forensic samples. Delusional love is usually intense in nature. Signs of denial of love by the object of the delusion are frequently falsely interpreted as affirmation of love. Patients may attempt to contact the object of the delusion by making phone calls, sending letters and gifts, making visits, and even stalking. Some cases lead to assaultive behaviors as a result of attempts to pursue the object of delusional love or attempting to "rescue" her/him from some imagined danger. Grandiose type Patients believe that they possess some great and unrecognized talent, have made some important discovery, have a special relationship with a prominent person, or have special religious insight. Grandiose delusions in the absence of mania are relatively uncommon, and the distinction of this subtype of disorder is debatable. Many patients with

Jealous type Related terms include conjugal paranoia, Othello syndrome, and pathological or morbid jealousy. The main theme of the delusions is that her or his spouse or lover is unfaithful. Some degree of infidelity may occur; however, patients with delusional jealousy support their accusation with delusional interpretation of "evidence" (eg, disarrayed clothing, spots on the sheets). Patients may attempt to confront their spouses and intervene in imagined infidelity. Jealousy may evoke anger and empower the jealous individual with a sense of righteousness to justify their acts of aggression. Both the intimate partner and the (perceived) lover may be the targets of aggression and violence. This disorder can sometimes lead to acts of violence, including suicide and homicide. Easton et al indicate thatDSM-IV-TRcriteria are not inclusive enough to diagnose this subtype. They looked at a database of 398 patients with a jealousy disorder and found that only 4% met diagnostic criteria for delusional disorder-jealous type. Persecutory type Most common type of delusional disorder. Most commonly associated with comorbid Axis 1 disorders. Patients believe that they are being persecuted and harmed. In contrast to persecutory delusions of schizophrenia, the delusions are systematized, coherent, and defended with clear logic. No deterioration in social functioning and personality is observed.

 Patients are often involved in formal litigation against their perceived persecutors. Munro refers to an article by Freckelton who identifies the following characteristics of deluded litigants: determination to succeed against all odds, tendency to identify the barriers as conspiracies, endless drive to right a wrong, quarrelsome behaviors, and "saturating the field" with multiple complaints and suspiciousness. Patients often experience some degree of emotional distress such as irritability, anger, and resentment.In extreme situations, they may resort to violence against those who they believe are hurting them. The distinction between normality, overvalued ideas, and delusions is difficult to make in some of the cases. Somatic type Related terms include monosymptomatic hypochondriasis. The core belief of this type of disorder is delusions around bodily functions and sensations. The most common are the belief that one is infested with insects or parasites, emitting a foul odor, parts of the body are not functioning, the belief that their body or parts of the body are misshapen or ugly, and the reduplication of body parts. Patients are totally convinced in physical nature of this disorder, which is contrary to patients with hypochondriasis who may admit that their fear of having a medical illness is groundless. Patients are usually first seen by dermatologists, cosmetic surgeons, urologists, gastroenterologists, and other medical specialists.

This must be distinguished from bizarre somatic delusions occasionally seen in schizophrenia (eg, a delusion that a colony of lobsters is living in the patients stomach).

Mixed type Patients exhibit more than one of the delusions simultaneously, and no one delusional theme predominates. The patient usually does not have comorbid Axis 1 disorders. Unspecified type Delusional themes fall outside the specific categories or cannot be clearly determined. Misidentification syndromes such as Capgras syndrome (characterized by a belief that a familiar person has been replaced by an identical impostor) or Fregoli syndrome (a belief that a familiar person is disguised as someone else) fall into this category. Misidentification syndromes are rare and frequently are associated with other psychiatric conditions (eg, schizophrenia) or organic illnesses (eg, dementia, epilepsy). Another unusual syndrome is Cotard syndrome, in which patients believe that they have lost all their possessions, status, and strength as well as their entire being, including their organs.Described first in the 19th century, it is a rare condition, which is usually considered a precursor to a schizophrenic or depressive episode.

Treatment General Considerations Delusional disorder is challenging to treat for various reasons, including patients' frequent denial that they have any problem, especially of a psychological nature, difficulties in developing a therapeutic alliance, and social/interpersonal conflicts. Treatment principles include the following: Establish a therapeutic alliance and negotiate acceptable symptomatic treatment goals. Start where "the patient is at," and offer empathy, concern, and interest in the experiences of the individual. With the appropriate permission from the patient, include the patient's family in decision-making and educate them. Consider the impact of culture for treatment planning. Avoid direct confrontation of the delusional symptoms to enhance the possibility of treatment compliance and response. Use medication judiciously to target core symptoms and associated problems (eg, anger). Use outpatient treatment unless there is potential for harm or violence. Tailor treatment strategies to the individual needs of the patient and focus on maintaining social function and improving quality of life. Recognize anda treat coexisting psychiatric disorders. Inpatient hospitalization should be considered if a patients delusions cause him or her to be a threat to self, others, or if he or she is deemed to be gravely disabled.

Psychopharmacological Treatment The evidence for the psychopharmacological treatment of delusional disorder would commonly be considered "grade C" (case series) or "grade D" (single case studies) evidence in many evidence-based medicine hierarchies. This is in contrast to randomized, blinded studies (grade A) or nonrandomized or nonblinded, but still systematically conducted, studies (grade B). Antipsychotics have been used since the 1970s when the first report was published on the use of pimozide for the treatment of monosymptomatic hypochondriacal psychosis (now classified as a delusional disorder, somatic type byDSM-IV-TR). Of approximately 1000 treated cases of delusional disorder from 1965-1985, a subanalysis of 257 best-described cases revealed that delusional disorder has a relatively good prognosis when adequately treated 52.6% of the patients recovered, 28.2% achieved partial recovery, and 19.2% did not improve. Treatment response was positive regardless of the specific delusional content. The data concluded that pimozide (68.5% recovery rate and 22.4% partial recovery rate) may be better than other typical antipsychotics (22.6% recovery and 45.3% partial recovery). Psychotherapy For most patients with delusional disorder, some form of supportive therapy is helpful. The goals of supportive therapy include facilitating treatment adherence and providing education about the illness and its treatment. Educational and social interventions can include social skills training (eg, not discussing delusional beliefs in social settings) and minimizing risk factors that may

Cognitive therapeutic approaches may be useful for some patients and this is best studied in persecutory type. The therapist helps the patient to identify maladaptive thoughts by means of Socratic questioning and behavioral experiments and then replaces them with alternative, more adaptive beliefs and attributions. Discussion of the unrealistic nature of delusional beliefs should be done gently and only after rapport with the patient has been established. Brief Psychotic Disorder Brief psychotic disorder is a short-term illness with psychotic symptoms. The symptoms often come on suddenly, but last for less than one month, after which the person usually recovers completely. There are three basic forms of brief psychotic disorder: Brief psychotic disorderwith obvious stressor(also called brief reactive psychosis):This type, also called brief reactive psychosis, occurs shortly after and often in response to a trauma or majorstress, such as the death of a love one, an accident or assault, or a natural disaster. Most cases of brief psychotic disorder occur as a reaction to a very disturbing event. Brief psychotic disorder without obvious stressor:With this type, there is no apparent trauma or stress that triggers the illness. Brief psychotic disorder with postpartum onset:This type occurs in women, usually within 4 weeks of having a baby.

Symptoms: Hallucinations:Hallucinations are sensory perceptions of things that aren't actually present, such as hearing voices, seeing things that aren't there or feeling sensations on your skin even though nothing is touching your body. Delusions:These are false beliefs that the person refuses to give up, even in the face of contradictory facts. Disorganized thinking Speech or language that doesn't make sense Unusual behavior and dress Problems with memory Disorientation or confusion Changes in eating orsleepinghabits, energy level, or weight Inability to make decisions What Causes Brief Psychotic Disorder? The exact cause of brief psychotic disorder is not known. One theory suggests a genetic link. This is based on the fact that the disorder is more common in people who have family members with mood disorders, such asbipolar disorder. Another theory suggests that the disorder is caused by poor coping skills, as a defense against or escape from a particularly frightening or stressful situation. These factors may create a vulnerability to develop brief psychotic disorder. In most cases, the disorder is then triggered by a major stress or traumatic event. Childbirthmay trigger the disorder in some women.

How Is Brief Psychotic Disorder Treated? Treatment for brief psychotic disorder typically includespsychotherapy(a type of counseling) and/or medication. Hospitalization may be necessary if the symptoms are severe or if there is a risk that the person may harm him or herself, or others. Medication:Antipsychotic drugs may be prescribed to decrease or eliminate the symptoms and end the brief psychotic disorder. Conventional antipsychotics include:Thorazine,Prolixin,Haldol,Navane, Stelazine,TrilafonandMellaril. Newer medications, called atypical antipsychotic drugs, include:Risperdal, Clozaril,Seroquel,GeodonandZyprexa. Tranquilizers such as Ativanor Valiummay be used if the person has a very high level ofanxiety(nervousness) and/or problems sleeping. Psychotherapy:Psychotherapy helps the person identify and cope with the situation or event that triggered the disorder.

Shared psychotic disorder Shared psychotic disorder, a rare and atypical psychotic disorder, occurs when an otherwise healthy person (secondary partner) begins believing thedelusionsof someone with whom they have a close relationship (primary partner) who is already suffering from a psychotic disorder with prominent delusions. This disorder is also referred to as "folie deux. In cases of shared psychotic disorder, the primary partner is most often in a position of strong influence over the other person. This allows them, over time, to

, this disorder occurs in a nuclear family. In fact, more than 95% of the cases reported involved people in the same family. Without regard to the number of persons within the family, shared delusions generally involve two people. There is the primary, most often the dominant person, and the secondary or submissive person. This becomes fertile ground for the primary (dominant) partner to press for understanding and belief by others in the family. Shared psychotic disorder has also been referred to by other names such as psychosisof association, contagious insanity, infectious insanity, double insanity, and communicated insanity. There have been cases involving multiple persons, the most significant being a case involving an entire family of 12 people (folie douze). Causes Given the fact that the preponderance of cases occur within the same family, the theory about the origins of the disorder come from a psychosocial perspective. Approximately 55% of secondary cases of the disorder have first-degree relatives with psychiatric disorders, not including the primary partner. This is not true of individuals with the primarydiagnosis, as they showed a roughly 35% incidence. There are several variables which have great influence on the creation of shared psychotic disorder. For example, family isolation, closeness of the relationship to the person with the primary diagnosis, the length of time the relationship has existed, and the existence of a dominant-submissive factor within the relationship. The submissive partner in the relationship may be predisposed to have a mental disorder. Often the submissive partner meets the criteria fordependent personality disorder. Nearly 75% of the delusions are of the

Symptoms The principal feature of shared psychotic disorder is the unwavering belief by the secondary partner in the dominant partner's delusion. The delusions experienced by both primary partners in shared psychotic disorder are far less bizarre than those found in schizophrenic patients; they are, therefore, believable. Since these delusions are often within the realm of possibility, it is easier for the dominant partner to impose his/her idea upon the submissive, secondary partner. Diagnosis A clinical interview is required to diagnose shared psychotic disorder. There are basically three symptoms required for the determination of the existence of this disorder: An otherwise healthy person, in a close relationship with someone who already has an established delusion, develops a delusion himself/herself. The content of the shared delusion follows exactly or closely resembles that of the established delusion. Some other psychotic disorder, such asschizophrenia, is not in place and cannot better account for the delusion manifested by the secondary partner. Treatments The treatment approach most recommended is to separate the secondary partner from the source of the delusion. If symptoms have not dissipated within one to two weeks, antipsychotic medications may be in order. Once stabilized,psychotherapyshould be undertaken with the secondary