Disorders Involving Loss of Contact with Reality

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Disorders Involving Loss of Contact with Reality
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Schizophrenia and Other Psychotic Disorders

• The core concept of the group is the presence of
  one or more of the following
• a significant distortion in the perception of
  reality
• an impairment in the capacity to reason, speak,
  and behave rationally or spontaneously
• and an impairment in the capacity to respond
  spontaneously with appropriate affect and
  motivation.

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Schizophrenia Subtypes

• Paranoid
• Preoccupation with persecutory delusions
• Disorganized
• Disorganized speech and behavior
• Catatonic
• Motor immobility, posturing, echolalia

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• Schizophreniform Disorder
• - (p. 319)
• Schizoaffective Disorder
• - (p. 323)
• Delusional Disorder
• - (p. 329)
• Brief Psychotic Disorder
• - (p. 332)

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• Shared Psychotic Disorder
• - (p. 334)
• Psychotic Disorder Due to a General Medical
  Condition
• - (p. 338)
• Substance-Induced Psychotic Disorder
• - (p. 342)
• Psychotic Disorder Not Otherwise Specified
• - (p. 343)

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Necessary Clinical Information

• History of documented psychiatric illness
• History of socially unusual, odd, or isolative
  behavior
• History of substance abuse
• History of medial illnesses
• Current experience of hallucinations or odd
  perceptual experiences
• Disorganized thought or speech
• Delusions
• Negative symptoms (e.g., flat affect, alogia,
  avolition)
• Positive symptoms (hallucinations and delusions)
• Depression or mania
• Duration of symptoms

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Dissociative Disorders

• Core Concept
• Temporary disruption in the normally integrated
  functions of memory, identity, or consciousness
  leading to amnesia, feelings of
  depersonalization, or multiple distinct
  personalities
• Dissociation splitting of mental processes from
  awareness
• Fugue- period of amnesia of which the person
  appears to be making rational decisions

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• Dissociative Fugue
• Amnesia usually accompanied by flight from home
• - (p. 526)
• Dissociative Amnesia
• Episode of inability to recall personal events,
  typically following traumatic event
• - (p. 523)
• Dissociative Identity Disorder
• (Multiple Personality)
• Two or more distinct identities
• - (p. 529)

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• Depersonalization Disorder
• Feelings of detachment from thought or body as if
  they were an outside observer
• - (p. 532)
• Dissociative Disorder NOS
• - (p. 532)

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Questions to ask in making a diagnosis include

• Could the patient's symptoms be produced by drugs
  or a nonpsychotic medical illness?
• Does the patient currently meet Criterion A
  (characteristic symptoms) of the common criteria
  set for Schizophrenia?
• Have the patient's symptoms lasted less than 6
  months?

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• Does the patient have a major depressive episode
  (including depressed mood) or manic episode
  concurrent with symptoms that meet Criterion A of
  the common criteria set for Schizophrenia?
• Does the patient have significant disorganized
  speech and behavior?
• Does the patient have unusual or peculiar motor
  activity?
• Does the patient have prominent hallucinations
  that he or she realizes are not real?
• Does the patient have bizarre delusions?

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• A 20-year-old apprentice electrician was
  hospitalized one month ago with acute confusion
  and psychosis, including looseness of
  associations and statements that God had spoken
  to him and given him great powers. He showed no
  severe blunting of affect. He was doing well, in
  his training and socially, until about three
  months ago, when he began to show deterioration
  in productivity and ability to concentrate. He
  drinks socially and has used marijuana
  occasionally, but there is no evidence of
  continuous abuse or other drug use. The patient
  has not recently been physically ill, is taking
  no prescribed medications, has a normal physical
  examination, and apparently has not been exposed
  to industrial or environmental toxins. At
  present, he has responded to hospitalization and
  medication, but is still delusional.

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• Diagnosis
• Axis I
• Axis II

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• Sandy is a 27-year -old woman who was admitted to
  a local psychiatric hospital after she
  superficially cut one wrist in a suicide attempt
  following a fight with her husband. She had been
  hospitalized twice in the last 7 years for
  similar suicide gestures and attempts. Her
  husband reported that the couple had been married
  for 5 years. He described the patient as
  impulsive and difficult to get along with because
  of her need for constant reassurance and her mood
  swings. "One minute she acts normal and a few
  minutes later she's depressed and angry about
  something. An hour later she starts her 'baby
  talk' routine, calls me 'Daddy,' and wants me to
  take care of her," he said. During extended
  interviews in the hospital, Sandy talked to the
  psychiatrist about feeling depressed and anxious
  much of the time. She agreed with her husband's
  report that she had a temper and often got angry
  at him. As the psychiatrist asked about her
  childhood, Sandy became quiet and looked away.
  "Is there something upsetting you?" she asked.
  Sandy looked at the psychiatrist and blinked a
  few times.

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• Her eyes seemed to lose focus briefly and she
  said in a childlike voice, "I'm afraid of you,
  cause, cause, you're going to be mean to me."
  The psychiatrist assured Sandy that she was safe.
  Sandy twisted her fingers together and said,
  "You sure you won't be mean to me?" The
  psychiatrist nodded and said, "You seem different
  than you were a few minutes ago, Sandy. What
  happened?" The patient looked confused and
  replied, "Who's Sandy? I'm Nan. I'll be 7 next
  week. Can you come to my party? My mommy says
  if I'm good I can have a party." The
  psychiatrist was startled and asked, "What
  happens if you're not good?" Nan looked down and
  began to cry, "Then, then, they punish me. I
  don't like it when they punish me. They put me
  in the closet forever," she said. The interview
  continued for several more minutes until Nan
  seemed briefly distracted again for a few
  seconds. "What's happening, Nan?" the
  psychiatrist asked. "My name's Sandy," the
  patient said.
• In additional interviews over the next several
  days the patient switched back and forth between
  the two identities of Sandy and Nan several
  times. Neither personality seemed to be aware of
  the other. Each personality had private memories
  and internally consistent patterns of thought and
  behavior that were separate from the other
  personality.