Psychosis: Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Hallucinations

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


  1. I came across your video while trying to find a better understanding of my disorder and it was very interesting and helpful!👍

  2. i'm just here to learn about mental disorders 🙂 i love learning things like this… you were right on point.

  3. I broke my nose at 3 years old. Now, as an adult I think I'm having olfactory hallucinations. Sometimes I smell odors that others don't smell

  4. i have started to get disorganized speech like the past 2 years and like i get this thing where i get smells that aren't there but like i dont even have to physically smell to get it and like ive had the smelling one my whole life and im 15 i dont know what it is

  5. Psychosis with mood disorder it says that it's caused by the mood that you're in can anyone tell me if a loved one suffers from psychosis says they only hear voices around their family and at home would that be part of mood disorder psychosis

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