Schizophreniform disorder (SFD) is characterized by the same basic features as schizophrenia , but with episodes lasting only one to six months. Hallucinations, delusions , and strange bodily movements or lack of movements (catatonic behavior) may be observed, or the patient may display peculiar speech, lack of drive to act on his/her own behalf, bizarre behavior, a wooden emotions or near-absent emotionality. However, in SFD, the patient’s social or occupational functioni diagnosis is changed to schizophrenia.
The person experiencing SFD shows at least two psychotic symptoms, which may be either “positive” or “negative.” Positive symptoms are those that are present but that do not normally occur or which are in excess of what normally occurs. Positive symptoms of psychosis include hallucinations, delusions, strange bodily movements or frozen movement (catatonic behavior), peculiar speech, and bizarre or primitive (socially inappropriate) behavior. Negative symptoms are factors that normally occur but are absent or deficient with the disorder. Various deficiencies in behavior, emotionality, or speech constitute the negative symptoms of psychosis that are observed in some cases of SFD. Negative symptoms ofpsychosis include avolition, affective flattening, and logia.
Avolition is a lack of effort to act on one’s own behalf or to engage in behaviors directed at accomplishing a purpose. Affective flattening or blunted affect refers to a decrease or low level of emotion,
shown as a wooden quality to one’s emotions or a near absence of emotionality. Alogia refers to a disruption in the thought process reflected in the person’s speech. One form of alogia is “poverty of speech.” Impoverished speech is brief, limited, and terse and generally emerges only in response to questions or prompts rather than flowing spontaneously. An impairment termed “poverty of content” occurs when the information or concepts that the individual is attempting to convey cannot be understood because of limitations in the method of communicating. The meaning behind the phrases is obscured or missing. Typically, in poverty of content, the person’s speech, while comprehensible in terms of its orderliness of grammar and vocabulary, does not convey substantial meaning because the phrasing is overly concrete and literal or overly abstract and fanciful.
Among the various positive symptoms of psychosis that can be a part of SFD, delusions are a fairly common. Delusions are strongly held irrational and unrealistic beliefs that are highly resistant to alteration. Even when the person encounters evidence that would invalidate the delusion, the unjustified and improbable belief remains a conviction. Often, delusions are paranoid or persecutory in tone. In these types of delusions, the person is excessively suspicious and continually feels at the mercy of conspirators believed to be determined to cause harm to the sufferer. However, delusions can also take on other overtones. Some delusions are grandiose, while others may involve elaborate love fantasies (erotomanic delusions). Delusions may involve somatic content, or may revolve around extreme and irrational jealousy.
Peculiar or disorganized speech, catatonic behavior, and bizarre or primitive behavior are all additional positive psychotic symptoms that may occur in SFD. Speech disorganization can involve words blended together into incomprehensible statements, also known as “word salad.” In some persons disorganized speech takes the form of echolalia, which is the repetition of another person’s exact spoken words, restated either immediately after the initial speaker or after a delay of minutes or hours. Catatonic behavior or catatonia involves the presence of one of the possible extremes related to movement. Catalepsy is the motionless end of the catatonic spectrum; in catalepsy, a person may remain unmoving in one fixed position for long periods. The opposite end of the catatonia phenomenon is demonstrated in rapid or persistently repeated movements, recurrent grimacing and odd facial expressions, and contorted or strange gestures. Bizarre or primitive behavior in SFD ranges from childlike behaviors in unsuitable circumstances to unusual practices such as hoarding refuse items perceived by the sufferer to be valuable, caching food all over the home, or wandering purposelessly through the streets.
Only rarely would all these various psychotic symptoms be observed simultaneously in one person with SFD. Instead, each individual with SFD has a constellation of symptoms, practices, and thought processes that is unique to that person.
Unlike any other diagnoses offered in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the SFD diagnosis always includes an indication of the patient’s prognosis—the potential outcome for an individual with a particular illness— based on the features observed and the usual course of the illness. If an individual with SFD has several positive prognostic factors, there is a much higher likelihood of complete recovery without relapse into psychosis. Such positive prognostic factors include prominent confusion during the illness, rapid (rather than gradual) development of symptoms during a four-week period, good previous interpersonal and goal-oriented functioning, and lack of negative symptoms of psychosis.
Causes and symptoms
Several views regarding the causes of the disorder have been put forth by researchers and clinicians.
AN EARLY PHASE OF ANOTHER PSYCHIATRIC DISORDER
A number of follow-up studies have examined the relationship between SFD and other disorders such as schizophrenia, schizoaffective disorder , and bipolar disorder . The majority of these studies have found that between 50% and 75% of persons with SFD eventually develop schizophrenia. Of those persons with a history of SFD who do not subsequently receive a diagnosis of schizophrenia, only a small portion have no further psychiatric disturbance. The other diagnoses that may be observed in persons formerly diagnosed with SFD are schizoaffective disorder or bipolar I disorder.
The most common subsequent diagnosis is schizophrenia, with the next most common being schizo-affective disorder. Because of the high rate of later schizophrenia in SFD sufferers, many clinicians have come to think of SFD as being an initial phase of schizophrenia. It is impossible to identify, during an episode of SFD, whether any one particular case will improve without any relapse into psychotic symptoms, or if the mental health client is actually in the early
phase of schizophrenia or schizoaffective disorder. Follow-up studies indicate that being frequently confused during a period of SFD is often associated with gradual complete recovery.
LENGTHY POSTPARTUM PSYCHOSIS
Intense hormonal changes occurring in childbirth and immediately afterward can result in a short-term psychotic disorder often referred to as “postpartum psychosis.” When the psychotic symptoms in this condition persist for more than one month but fewer than six months, an SFD diagnosis may be given.
DIATHESIS AND STRESS
“Diathesis” is a medical term meaning that some element of one’s physiology makes one particularly prone to develop an illness if exposed to the right conditions. Diathesis is another way of saying there is a personal predisposition to develop a disorder; the predisposition is biologically based and is genetically acquired (inherited in the person’s genes). Temporary psychotic reactions may occur in persons who have the diathesis for psychosis, when the individual is placed under marked stress . The stress may result from typical life transition experiences such as moving away from home the first time, being widowed, or getting divorced. In some cases, the stressor is more intense or unusual, such as surviving a natural disaster, wartime service, being taken hostage, or surviving a terrorist attack. When the psychotic responses last less than a month, then this reaction is labeled “brief psychotic disorder.” Highly susceptible persons may show psychotic symptoms for longer than one month and might be given the SFD diagnosis. If the psychotic symptoms are purely reactive, when the stressor ceases or more support is available, the individual is likely to return to a nonpsychotic mode of functioning. In persons with a strong diathesis or predisposition, the initial psychotic reaction may “tip over” from the category of a brief reaction into a longer-term, persistent psychiatric disorder. The diathesis-stress model is applied not only to SFD, but also to schizophrenia, schizoaffective disorder, and the most severe forms of mood disorders.
CULTURALLY DEFINED DISORDERS
Many cultures have forms of mental disorder, unique to that culture, that would meet criteria for SFD. In culturally defined disorders, a consistent set of features and presumed causesof the syndro me are localized to that community. Such disorders are termed “culture-bound.” Examples of culture-bound syndromes that might meet SFD criteria are “amok” (Malaysia), or “locura” (Latino Americans). Amok is a syndrome characterized by brooding, persecutory delusions, and aggressive actions. Locura involves incoherence, agitation, social dysfunction, erratic behavior, and hallucinations.
The DSM-IV-TR provides three major criteria for SFD. First, the patient must display at least two persistent positive or negative symptoms of psychosis (delusions; disorganized speech that is strange, peculiar, or difficult to comprehend; disorganized, bizarre, or childlike behavior; catatonic behavior; hallucinations; or negative symptoms). In addition, the symptoms must be manifest for a limited time (i.e., at least one month, but less than six months). Third, the symptoms must not be attributable to biological influences (e.g., drugs, medication, alcohol, physical illness or injury) or another disorder (e.g., schizoaffective disorder or schizophrenia).
The actual rate of SFD is unknown, mainly because SFD is difficult to measure except in retrospect. In the first few weeks of symptoms, SFD cannot be differentiated from brief psychotic disorder . Once the symptoms persist past one month and are identified as SFD, six months or more must pass before one can determine if a mental health consumer had “classic” SFD or was in the early phase of a more chronic mental disorder. Given that a majority of SFD sufferers go on to be diagnosed with schizophrenia, the best inferences about demographics and gender differences in SFD would be drawn from similar information available regarding schizophrenia.
Despite the clarity of the DSM-IV-TR criteria, identification of SFD is less than clear-cut. The emphasis on the length of time that symptoms have been evident and the presence or absence of good prognostic factors make SFD one of the most unusually defined of the DSM-IV-TR disorders. While duration of symptoms is the major distinction among brief psychotic disorder, SFD, and schizophrenia, it can be difficult to clearly determine the length of time symptoms have existed. An additional complication is that the cultural context in which the “psychotic symptoms” are experienced determines whether the behaviors are viewed as pathological or acceptable. When psychotic-like behaviors are expected to occur normally as part of the person’s culture or religion, and when the behaviors occur in a culturally positive context such as a religious service, SFD would not be diagnosed.
Information about current and past experiences is collected in an interview with the client, and possibly in discussion with the client’s family. Psychological assessment instruments (e.g., Rorschach technique , Minnesota Multiphasic Personality Inventory , and mood disorder questionnaires) or structured diagnostic interviews may also be used to aid in the diagnosis.
In addition, part of defining SFD involves examining possible biological influences on the development of the individual’s psychotic symptoms. When the psychotic features result from a physical disease, a reaction to medication, or intoxication with drugs or alcohol, then these symptoms are not considered SFD. Also, if hallucinations, delusions, or other psychotic symptoms are experienced solely during episodes of clinical depression or mania, the patient is diagnosed with a mood disorder rather than SFD.
The main line of treatment for SFD is antipsychotic medication. These medications are often very effective in treating SFD. Mood-stabilizing drugs similar to those used in bipolar disorder may be used if there is little response to other interventions. Postpar-tum psychosis is also treated with antipsychotics and, possibly, hormones. Supportive therapy and education about mental illness is often valuable. The most useful interventions in culture-bound syndromes are those that are societally prescribed; for example, a sacred ceremony to ease the restless spirits of deceased ancestors might be a usual method of ending the psychotic-like state, in that particular culture.
For the large number of mental health patients with SFD who are later diagnosed with a more chronic form of mental illness, the prognosis is fairly poor. However, when the condition manifests with prominent confusion during the illness, rapid (rather than gradual) development of symptoms during a four-week period, good previous interpersonal and goal-oriented functioning and lack of negative symptoms of psychosis, a full recovery is much more likely
If the SFD is a persistent postpartum psychosis, a prevention option is to avoid having additional children. The physician may anticipate the postpartum problem and prescribe an antipsychotic medication regimen to begin immediately after delivery as a preventive measure. Although prevention of psychotic disorders is difficult to accomplish, the earlier treat
Erotomanic delusions —Erotomanic delusions involve the mistaken conviction that someone is in love with the delusional person. Often, the love object is a public figure of some prominence, such as an actress, rock star, or political figure. David Letter-man and Jodie Foster are celebrities who have both been victimized by persons with erotomanic delusions.
Grandiose delusions —Grandiose delusions magnify the person’s importance; the delusional person may believe himself or herself to be a famous person, to have magical superpowers, or to be someone in a position of enormous power (such as being the king or president).
Hallucinations —False sensory perceptions. A person experiencing a hallucination may “hear” sounds or “see” people or objects that are not really present. Hallucinations can also affect the senses of smell, touch, and taste.
Psychosis —Severe state that is characterized by loss of contact with reality and deterioration in normal social functioning; examples are schizophrenia and paranoia. Psychosis is usually one feature of an overarching disorder, not a disorder in itself (Plural: psychoses.)
Somatic —Somatic comes from soma, the Greek word for body; thus, somatic hallucinations are bodily. Somatic delusions are strongly held but erroneous ideas about the characteristics or functioning of one’s body. An example is a mental health client who refuses to eat because of a belief that there is a hole in the stomach that will spill anything consumed into the body cavity, when such is not actually the case.
ment begins, the better the outcome. Therefore, efforts are more generally focused on early identification of SFD and other psychotic-spectrum disorders.
See alsoBrief psychotic disorder; Delusional disorder; Schizotypal personality disorder.
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Deborah Rosch Eifert, PhD Ruth A. Wienclaw, PhD