Schizophreniform Disorder

Schizophreniform disorder is a serious mental disorder with symptoms similar to those of schizophrenia. Early diagnosis of this disorder is crucial, as is early intervention with medication, supportive therapy, and patient and family education.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), ^[1] schizophreniform disorder is characterized by the presence of the symptoms of schizophrenia, including delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms. The disorder, including its prodromal, active, and residual phases, lasts longer than 1 month but less than 6 months.

Unlike schizophrenia, in which prodromal symptoms may develop over several years, schizophreniform disorder requires, among other features, a rather rapid period from the onset of prodromal symptoms to the point at which all criteria for schizophrenia (except duration and deterioration) are met (≤6 months).

Diagnostic criteria (DSM-5-TR)

The specific DSM-5-TR criteria for schizophreniform disorder are as follows: ^[1]

• The presence of 2 (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated), with at least 1 of them being (1), (2), or (3): (1) delusions, (2) hallucinations, (3) disorganized speech, (4) grossly disorganized or catatonic behavior, and (5) negative symptoms

• An episode of the disorder lasts at least 1 month but less than 6 months; when the diagnosis must be made without waiting for recovery, it should be qualified as “provisional”

• Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms or (2) any mood episodes that have occurred during active-phase symptoms have been present for a minority of the total duration of the active and residual periods of the illness

• The disturbance is not attributable to the physiologic effects of a substance (eg, a drug of abuse or a medication) or another medical condition ^[2]

Schizophreniform disorder is further specified as being either with or without good prognostic features. ^[1] The specifier “with good prognostic features” requires the presence of at least 2 of the following:

• Onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior of functioning

• Confusion or perplexity

• Good premorbid social or occupational functioning

• Absence of blunted or flat effect

In the absence of 2 or more of these 4 features, the specifier “without good prognostic features” is employed.

Patients with schizophreniform disorder and patients with schizophrenia share many anatomic and functional cortical deficits on neuropsychological studies, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT), and positron emission tomography (PET).

A study of delay-dependent memory performed by Mathes et al found that patients with schizophreniform disorder and schizophrenia were less able to form an internal representation of complex objects. ^[3] Such neuropsychological tests help clinicians further understand the psychopathology of the disorder.

The study by Mathes et al investigated 55 patients with schizophreniform psychosis, 50 patients with established schizophrenia, and a control group of 56 healthy controls, using the delayed matching-to-sample task from the Cambridge Neuropsychological Test Automated Battery (CANTAB). ^[3] Performance deficits were found in both patient groups after age and premorbid intelligence quotient (IQ) were controlled for.

Even when simultaneous matching-to-sample ability (ie, perceptual matching) was controlled for, impaired performance in both patient groups was found as soon as the stimuli were removed. ^[3] Impaired performance was not due to different types of performance errors in patients as compared with control individuals. Performance in the 2 patient groups was comparable, except for a slight decrease in overall task performance. These findings suggest that the deficit is relatively stable during the course of the illness.

The similarity of the deficits notwithstanding, schizophreniform disorder is distinct from schizophrenia. This distinction was confirmed by a trial by Sautter et al, which compared the courses of illness (including positive and negative symptoms of psychosis, interpersonal and occupational role functioning, and other aspects of the deficit) in 36 patients who received a diagnosis of either schizophreniform disorder or schizophrenia. ^[4]

Approximately 3.5 and 4 years after their initial index hospitalization, the 2 groups of patients were compared. ^[4] In the patients with schizophreniform disorder, the level of negative symptoms was low at both follow-up examinations. In the patients with schizophrenia, however, the level of negative symptoms was higher at first but fell significantly over time. The findings of this trial indicate that the course of schizophreniform disorder differs from that of schizophrenia.

The prevalence of schizophreniform disorder, like that of schizophrenia, is equally distributed between the sexes, with peak onset between the ages of 18 and 24 years in men and between the ages of 24 and 35 years in women.

The persistence of symptoms beyond 6 months predicts a worse prognosis for schizophrenia as compared with schizophreniform disorder. Clarke et al demonstrated that a longer period of untreated psychosis was linked with a significantly worse functional and symptomatic outcome at 4 years’ follow-up. ^[5]

Confusion and perplexity at the height of the psychotic episode correlates with better outcome in schizophreniform disorder. A significant risk of suicide exists in patients with this disorder, especially when they are more likely to go into a depression after the psychotic period. ^[6] Psychotherapy during this phase, aimed at helping patients understand the psychotic episodes, is likely to improve the prognosis and enhance recovery. Drake et al found that patients who acquired better insight into their illness were less likely to experience relapse. ^[7]

Fraguas et al examined the diagnostic stability and the functional outcome of patients with early-onset psychosis, including schizophreniform disorder, over a 2-year follow-up period; they found a 50% predictability for future psychotic episodes for schizophreniform disorder and cited the presence of negative symptoms as a predictor of lower level of functioning at the end of 2 years. ^[8]

According to the American Psychiatric Association, approximately two thirds of patients diagnosed with schizophreniform disorder progress to a diagnosis of schizophrenia. According to Benazzi et al, patients with a good prognosis tend to be retrospectively associated with the affective spectrum of diagnoses rather than the schizophrenic. ^[9]

According to Troisi et al, in some patients with a schizophreniform disorder, the presence of negative symptoms and poor eye contact appear to be prognostic of a poor outcome. ^[10] Studies have not yet elicited a consensus about whether ventricular enlargement is predictive of poor outcome in patients with a schizophreniform disorder.

Efforts should be made to educate both patients and their families about the early signs of relapse and the need for continuing treatment. Such efforts advance the overall aim of helping patients regain productive roles in society while reducing the risk of relapse. Families with a high degree of emotional expression are likely to cause additional stress to the patient and to increase the likelihood of relapse.

The patient’s condition, the patient’s family, and the patient’s system of care are a few of the many factors that likely affect treatment engagement early in the course of schizophreniform disorder and schizophrenia. Clinicians should give special attention to these factors when caring for patients who experience their first episode of schizophreniform disorder.

The following links provide valuable information for patients and their families:

• Schizophrenia - National Institute of Mental Health (NIMH)

• American Psychiatric Association

• Schizophrenia Research Forum

For patient education resources, see the Mental Health and Behavior Center, as well as Schizophrenia.