Psychotic Disorders

by

Deborah J. Walder, Marta Statucka, Maureen Daly, Beril Yaffe

• LAST REVIEWED: 28 April 2014
• LAST MODIFIED: 28 April 2014
• DOI: 10.1093/obo/9780199828340-0151

Introduction

The term “psychotic disorders” refers to a broad conceptualization of conditions including primary psychoses, such as schizophrenia and psychotic mood disorders, other disorders that are sometimes marked by psychotic features (e.g., borderline personality disorder, body dysmorphic disorder), and secondary psychotic disorders due to medical conditions or substances (e.g., alcohol withdrawal delirium). As addressed in Ketter, et al. 2004 (“Psychotic Bipolar Disorders: Dimensionally Similar to or Categorically Different from Schizophrenia?,” cited in the Debate of Dimensional versus Categorical), controversy regarding relationships among mood disorders (particularly bipolar and depressive disorders with psychotic features) and schizophrenia is ongoing. The authors argue that while the respective dimensional (e.g., psychotic bipolar disorder as intermediate between non-psychotic bipolar and schizophrenia spectrum disorders) versus categorical debate persists, a mixed dimensional/categorical approach may best help elucidate pathophysiology and treatment options. Schizophrenia, specifically, is a severe and persistent form of mental illness often marked by positive symptoms (such as excesses and distortions in thoughts and sensory/perceptual experiences such as hallucinations and delusions), negative symptoms (behavioral deficits such as avolition, asociality, anhedonia, blunted affect, and alogia), disorganized symptoms (such as disorganized speech and behavior), movement symptoms (or grossly abnormal psychomotor behavior such as catatonia), and impairments in cognition (such as memory and frontal/executive functions that include, for example, planning ability and initiation). Kring, et al. 2014 (Abnormal Psychology, cited under the Schizophrenia Spectrum) provides an excellent introductory-level overview of schizophrenia and other psychotic disorders. The etiological (or causal) basis of schizophrenia and related psychotic disorders remains not wholly determined. Prevailing theories, however, ascribe to a diathesis-stress model, whereby biological factors (e.g., predispositions such as genetic liability) are believed to interact with adverse environmental factors (e.g., obstetric complications; adverse, stressful life events) over the course of development toward the manifestation of illness. This article offers a historical perspective of psychotic disorders, a review of etiological/theoretical models, a description of illness epidemiology and issues pertaining to sex differences and comorbidity, an outline of diagnostic considerations, a description of the schizophrenia spectrum, an examination of available assessment tools, the role of cognition/social cognition, a review of current evidence of neurobiological disruptions in psychosis (e.g., genetics, structural and functional neuroimaging, hormones, neurotransmitters, other aspects of maldevelopment in the central nervous system), other laboratory markers (e.g., perceptual and attentional abnormalities, smooth-pursuit eye movement dysfunction), environmental factors (such as stress, toxins, and familial-expressed emotion), the importance of gene-environment interactions in psychotic disorders, and, finally, current directions pertaining to prevention and treatment (pharmacological and psychosocial). While various psychotic-related disorders are addressed, this article focuses on the schizophrenia spectrum.

Historical Context

These papers introduce the work of Emil Kraepelin and Eugen Bleuler, two integral figures in the conceptualization of schizophrenia. Palha and Esteves 1997 presents a short history of psychiatry, from ancient civilizations through the 19th century, describing how Kraepelin synthesized previous work to form his nosologic system of psychopathology. Palm and Möller 2011 reviews Kraepelin’s nosology and its reception by his peers during the early 20th century, after its initial publication. A comparison of Kraepelin and Bleuler in terms of personality and personal history, approach to patients, and sociohistorical factors that influenced their unique conceptualizations of schizophrenia is provided in Kaplan 2008. Though Kraepelin’s nosologic system remains the basis for modern psychiatry, Hoff 2012 argues that Bleuler’s conceptualization of schizophrenia represented a drastic progression from Kraepelin’s work, by introducing a multidimensional approach and a precursor to modern diathesis-stress models. For a summary of Bleuler’s contributions to our understanding of schizophrenia, refer to Cuesta and Peralta 2011, the special edition of Schizophrenia Bulletin celebrating the centennial of Bleuler’s Dementia Praecox or the Group of Schizophrenias. This issue of Schizophrenia Bulletin also contains relevant contributions by Berrios 2011 and McGlashan 2011. However, over the years Bleuler’s conceptualization has been simplified and distorted, leading to many misinterpretations and unfounded criticisms of his work, as outlined in Moskowitz and Heim 2011. As argued in McNally 2009, this is especially true of the “Four A’s,” which has been used as a mnemonic of Bleuler’s work for many years but inaccurately summarizes his conceptualization of schizophrenia. From a historical and sociological perspective, additional important theoretical considerations are those posited by the “antipsychiatry” movement. Nasrallah 2011 briefly reviews the antipsychiatry movement, its primary propagators, and their claims. Nasrallah emphasizes that despite the assertions of antipsychiatry, which are largely believed to be “. . . unfair exaggerations based on events and primitive conditions of more than a century ago,” it is important because it helps keep the field of psychiatry “. . . honest and rigorous about what we do, motivating us to relentlessly seek better diagnostic models and treatment paradigms.” At present, the schizophrenia spectrum is conceptualized as including not only major psychotic disorders such as schizophrenia and schizoaffective disorder, but also the cluster A (“odd, eccentric”) personality disorders, each of which approximates some features of schizophrenia in an attenuated form. Cluster A personality disorders include paranoid personality disorder (characterized by a pervasive lack of trust in others), schizoid personality disorder (characterized by a tendency to be socially isolated and not interested in close relationships), and schizotypal personality disorder (SPD; characterized by a tendency to be socially isolated, reserved, and distant, accompanied by frequently experienced perceptual abnormalities). There are higher rates of SPD among family members of patients with schizophrenia than in the general population, and there is a relatively higher rate of transition to psychosis among individuals with SPD (see the Schizophrenia Spectrum).

• Berrios, G. E. 2011. Eugen Bleuler’s place in the history of psychology. Schizophrenia Bulletin 37.6: 1095–1098.

  DOI: 10.1093/schbul/sbr132

  An editorial advocating for Bleuler’s place in the “pantheon of psychiatry” and encouraging further research into his concept of schizophrenia as well as his other works.

• Cuesta, M. J., and Peralta, V., eds. 2011. Theme: Bleuler’s contribution to contemporary psychiatry. Schizophrenia Bulletin 37.6: 1118–1146.

  Issue celebrating the publication of Bleuler’s Dementia Praecox or the Group of Schizophrenias in 1911. Contains articles outlining Bleuler’s seven main contributions (Peralta and Cuesta, pp. 1118–1120), tracing the descriptive features of schizophrenia introduced by Kraepelin and Bleuler to the current diagnostic criterion (Parnas, pp. 1121–1130), and proposing progress toward a neurobiological understanding of schizophrenia (Heckers, pp. 1131–1135).

• Hoff, P. 2012. Eugen Bleuler’s concept of schizophrenia and its relevance to present-day psychiatry. Neuropsychobiology 66.1: 6–13.

  DOI: 10.1159/000337174

  Outlines how Bleuler was influenced by Kraepelin, Johann Friedrich Herbart, and Sigmund Freud. Argues that Bleuler’s conceptualization of schizophrenia represents clear progress from previous conceptualizations (including Kraepelin’s), citing his multidimensional approach and his introduction of a framework suggestive of modern diathesis-stress models.

• Kaplan, R. M. 2008. Being Bleuler: The second century of schizophrenia. Australasian Psychiatry 16.5: 305–311.

  DOI: 10.1080/10398560802302176

  Provides brief biographies of Kraepelin and Bleuler and describes and contrasts the historical, cultural, and social factors influencing their work. Also provides a brief but compelling comparison of their personalities, relationships with patients, and conceptualization of schizophrenia.

• McGlashan, T. H. 2011. Eugen Bleuler: Centennial anniversary of his 1911 publication of Dementia Praecox of the Group of Schizophrenias. Schizophrenia Bulletin 37.6: 1101–1103.

  DOI: 10.1093/schbul/sbr130

  An article that clearly and concisely summarizes Bleuler’s diagnostic and therapeutic contributions.

• McNally, K. 2009. Eugene Bleuler’s Four As. History of Psychology 12.2: 43–59.

  DOI: 10.1037/a0015934

  Describes how Bleuler’s complex theory was gradually simplified and distorted into the Four A’s (disturbed Affect and Associations, Ambivalence, Autism). Demonstrates how this led to misinterpretation and unfounded criticism of Bleuler, and emphasizes the importance of other symptoms in Bleuler’s conceptualization (especially splitting of personality).

• Moskowitz, A., and G. Heim. 2011. Eugen Bleuler’s Dementia praecox or the group of schizophrenias (1911): A centenary appreciation and reconsideration. Schizophrenia Bulletin 37.3: 471–479.

  DOI: 10.1093/schbul/sbr016

  Clarifies four myths regarding Bleuler’s conceptualization, including the inadequacy of the Four A’s. Argues that DSM-5 requires a neo-Bleulerian perspective deemphasizing the importance of psychotic symptoms.

• Nasrallah, H. A. 2011. The antipsychiatry movement: Who and why. Current Psychiatry 10.12: 4, 6, 53.

  Briefly reviews the antipsychiatry movement, its primary propagators (such as Michel Foucault, David Cooper, Erich Fromm, R. D. Laing, and Thomas Szasz) and their claims, which question the legitimacy of the concept of schizophrenia. Highlights that despite the inaccurate claims of antipsychiatry, which are based on obsolete information, these views help keep the field of psychiatry “. . . honest and rigorous about what we do, motivating us to relentlessly seek better diagnostic models and treatment paradigms.”

• Palha, A. P., and M. F. Esteves. 1997. The origin of dementia praecox. Schizophrenia Research 28.2–3: 99–103.

  DOI: 10.1016/S0920-9964(97)00117-5

  Short historical review of psychiatry’s origins in ancient civilizations, the church’s influence during the Middle Ages, the resurgence of psychiatry during the Enlightenment, the first biological models of mental illness in the 19th century, and how Kraepelin synthesized others’ work and created his nosologic system.

• Palm, U., and H.-J. Möller. 2011. Reception of Kraepelin’s ideas 1900–1960. Psychiatry and Clinical Neurosciences 65.4: 318–325.

  DOI: 10.1111/j.1440-1819.2011.02226.x

  While Kraepelin’s nosology received harsh criticism from 1900 to 1926, it was quickly and broadly accepted thereafter and forms the basis of current diagnostic tools. Presents several criticisms of Kraepelin’s system but argues that it is the foundation of modern psychiatry due to its simplicity and clarity.