Distinguished future physicians welcome to Stomp on Step 1 the only free videos series
that helps you study more efficiently by focusing on the highest yield material.
I’m Brian McDaniel and I will be your guide on this journey through Schizophrenia and
other Psychotic Disorder like Schizoaffective, Delusional Disorder and Schizophreniform Disorder.
This is the 2nd video in my playlist covering psychiatry.
Psychosis is disorganized thoughts and a distorted perception of reality.
Psychotic individuals will usually have a loss of function and a lack of insight (they
don’t realize their perception of reality is distorted).
There are a few different types of psychotic symptoms which we will review individually.
Hallucinations are hearing, seeing, feeling, tasting or smelling something that isn’t
really there.
This sensation has no external stimuli.
Due to the lack of insight these individuals think that what they perceive is real.
Schizophrenia is usually associated with auditory hallucinations where the individual hears
voices.
Tactile Hallucinations like the sensation of bugs crawling on their skin is usually
related to street drugs.
Olfactory (smell) hallucinations are more commonly seen in the aura before seizures.
Delusions are strongly held beliefs that are not based on fact.
Due to the lack of insight trying to convince a psychotic person that their delusions are
false is almost impossible no matter of how much evidence you present.
Delusions of Persecution are the most common type and involve paranoia.
These individuals think others are “out to get them” and are trying to follow them,
spy on them, poison them, steal from them or otherwise harm them.
Delusions of Grandeur are when an individual believes that have special powers, talents
or intellect.
They may think they are famous, have supernatural abilities or have religious prominence.
Other common themes in delusion are guilt, thought control, thought broadcasting (belief
that others can hear your thoughts) and ideas of reference (belief that people on TV/radio/print
media are talking about you).
Disorganized Speech or thought disorder is random, incoherent speech that may involve
repeating phrases or words that sound similar.
The patient likely is not aware that their speech makes no sense to others.
This is sometimes referred to as “Word Salad.”
Catatonia is motor hyperactivity with repetitive purposeless motions or motor hypoactivity
that leads to complete motor immobility & waxy flexibility (you can move the patient into
an odd position and they will stay in that position for hours).
It can include a complete disconnect from reality.
Here is an example of waxy flexibility.
If you moved a cataonic person into this position they would be able to stay there without moving
for hours.
A catatonic state should not be confused with Cataplexy which is a type of narcolepsy where
people have motor immobility while remaining completely aware of their surroundings.
In the previous video in the Psychiatry section
we covered mood disorders.
There we briefly discussed Mania with psychosis and depression with psychosis.
The key difference between schizophrenia and a mood disorder with psychosis is that the
psychosis in mood disorders is “Mood Congruent.”
This means that the psychosis is only present during mood “episodes” and that the psychosis
is in line with their mood.
So a manic individual may have delusions of grandeur and a depressed person might have
delusions of guilt.
You can see here in the top right corner I give Schizophrenia a high yield rating of
3.
The high yield rating is a scale from 0 to 10 that gives you an estimate of how important
each topic is for the USMLE Step ! Medical Board Exam based on a number of factors including
how often each topic appears on retired Step 1 questions.
To Learn more about the high yield rating you can click this orange box here.
Schizophrenia is a chronic progressive psychiatric condition characterized by psychosis and an
abnormal interpretation of reality.
They have a difficult time functioning in society due to progressive loss of function.
Symptoms are categorized into 2 groups, Negative and Positive Symptoms.
Positive symptoms are behaviors or sensations that are not normally present.
These symptoms are may be related to an excess of dopamine.
Examples include hallucinations, delusions, catatonia & disorganized speech/behavior
Negative symptoms = The absence of normal behavior.
Examples include a lack of initiative, diminished speech, disheveled appearance & flat affect.
There used to be specific subtypes of Schizophrenia based on what types of psychosis were predominate,
but the difference between those types was low yield and in the most recent version of
the DSM those subtypes have been removed.
To make a diagnosis of schizophrenia you need to rule out other potential causes of psychosis.
Street drugs like cocaine or hallucinogens as well as prescription medications like corticosteroids
or antiparkinsonian drugs can cause psychosis.
General medical conditions such as stroke, delirium, and dementia also need to be ruled
out from the differential diagnosis.
Thankfully these intricacies are a bit beyond the scope of the USMLE Step 1 exam.
If the question stem has a clear picture of psychosis you can safely choose Schizophrenia
unless there is a big hint like a recent use of cocaine.
We will cover treatment for psychosis like antipsychotics in a later video in the section.
The same group of symptoms are associated with different diagnoses based on their duration.
According the DSM, Schizophrenia must have symptoms that persist for more than 6 months.
If the same symptoms are present for less than a month you have a different diagnosis.
Symptoms of schizophrenia for less than 1 month is referred to as brief psychotic disorder
and symptoms for 1 to 6 months is schizophreniform Disorder
Schizoaffective Disorder is a mood disorder in the presence of a psychotic disorder.
It can be thought of as Schizophrenia plus Major Depressive Disorder or Bipolar Disorder.
Differentiating between schizoaffective disorder and a mood disorder that has psychotic features
can be challenging.
Thankfully this is a bit beyond the scope of the exam, but the key is what symptoms
are predominant.
In Schizoaffective disorder psychosis is the primary symptom and changes in affect only
occasionally occur during psychotic episodes.
These individuals will not be depressed or manic in the absence of psychosis.
Alternatively, a Bipolar person will primarily have mood symptoms and will only occasionally
have psychosis during a depressive or manic episode.
They will not have psychotic symptoms when they are in a euthymic state (or neutral mood).
Delusional Disorder is characterized by a delusion and the lack of other psychotic symptoms
(no hallucinations or thought disorder).
These individuals do not have loss of function and may appear normal most of the time.
Unlike the delusions in Schizophrenia, the delusion in Delusional Disorder is usually
fixed and non-bizarre.
So while the delusion is not based on reality it is at least plausible.
A bizarre delusion would be something like “aliens abducted me” while a non-bizarre
delusion would be something like “my neighbor is trying to kill me” which could potentially
occur in real life.
The prefix Schizo means “split”.
This has unfortunately led to a lot of confusion in the media and general public.
Many believe Schizophrenia is a type of split personality disorder (AKA Dissociative Identity
Disorder) when the two disorders are not related.
The split prefix actually refers to the gap between a schizophrenic person and reality.
This prefix applies to many of the disorders within the “Schizophrenia Spectrum and Other
Psychotic Disorders” category, which is a new title added to the latest version of
the DSM.
Schizoid Personality Disorder, Schizotypal Personality Disorder, Schizophrenia and Schizoaffective
Disorder all have a detachment from reality and/or others.
These disorders also share features like blunted affect.
Individuals with a family history of schizophrenia are more likely to be schizoid, schizotypal
or schizoaffective.
As a memory mnemonic you can think of there being a continuum from Schizoid to Schizoaffective
where each successive step has most of the characteristics of the previous step plus
additional symptoms.
The way I remember this is that as the number of letters increases so do the number of symptoms.
Schizoid Personality Disorder is when a person is very introverted and voluntarily withdraws
from social interactions.
Schizotypal can be thought of as Schizoid symptoms plus magical thinking & odd behavior.
Schizophrenia can be thought of a Schizotypal symptoms plus psychosis and as we have already
discussed Schizoaffective disorder is basically Schizophrenia plus a Mood Disorder.
Schizophreniform unfortunately does not fit into this mnemonic.
We will cover Schizoid and Schizotypal in much more detail in a later video about Personality
Disorders
That brings us to the end of the video.
If you liked it and would like to make it easier to find other videos from Stomp On
Step 1 you can click on this orange box here.
Our next video in the series will cover Anxiety disorders like OCD, PTSD & Generalized Anxiety
Disorder.
If you would like to be taken directly to that video you can click on this black box
here