September 2021

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Psychotic symptoms are sometimes found in people with bipolar disorder, particularly in the manic phase of the illness. The severity of psychotic symptoms can significantly affect a person’s day-to-day functioning, quality of life, and cognition.

Psychotic symptoms most commonly involve hallucinations and delusions. Hallucinations are defined as a perceptual experience that occurs in the absence of any corresponding external sensory input. They are most commonly auditory, but can occur in any modality. Delusions are fixed, false beliefs that persist regardless of contradictory evidence, and are not explained by cultural beliefs. Persecutory delusions involve the belief that people are attempting to harm or even kill the individual. Delusions of reference refer to beliefs that neutral events are directed specifically towards the individual. Somatic delusions involve the belief that the individual has a serious physical disease or alteration of the body. Delusions of grandeur are characterised by an exaggerated belief that the individual has extraordinary powers, abilities, or fame.

What is the evidence for psychotic symptoms?

Moderate quality evidence suggests the prevalence of visual hallucinations in people with affective psychosis is around 15%, and the prevalence of auditory hallucinations is around 28%. These rates are lower than in schizophrenia (visual = 27%, auditory = 59%), Parkinson’s disease (15-40%), dementia with Lewy bodies (60-90%), age-related eye disease (10-60%), and death-bed visions (50%). They are higher than general population rates (7%).

Auditory hallucinations are more common than visual, olfactory, tactile or gustatory hallucinations, are most common in the early stages of bipolar disorder, and in people with bipolar disorder and a history of childhood abuse.

Moderate to low quality evidence suggests the lifetime frequency of delusions is higher than the lifetime frequency of auditory hallucinations (66-82% vs. 23-31%). Rates of delusions and auditory hallucinations are higher in people in a manic episode than in people in a depressive episode. Rates of auditory hallucinations are most common in people with mixed-manic presentations.

September 2021

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Schizophrenia is characterised by positive, negative and disorganised symptoms. Positive symptoms refer to experiences additional to what would be considered normal experience, such as hallucinations and delusions. Negative symptoms include blunted affect, impoverished thinking, alogia, asociality, avolition, and anhedonia. Alogia is often manifested as poverty of speech, asociality involves reduced social interaction, avolition refers to poor hygiene and reduced motivation, while anhedonia is defined as an inability to experience pleasure. Disorganised symptoms involve bizarre behaviour and disorganised thought and speech. Cognitive deficits are also a core feature of schizophrenia. These deficits may be present in chronic patients, as well as prior to onset of the disorder and during its early and acute stages. Cognitive deficits may be associated with specific symptoms as well as functional impairment.

What is the evidence for cognitive functioning relating to symptom dimensions?

Moderate to high quality evidence shows more severe overall symptoms are associated with poor prospective memory, insight, executive functioning, facial perception, facial emotion recognition, emotion processing and perception, social perception, and Theory of Mind.

More severe positive symptoms are associated with poorer insight, attention/vigilance, reasoning, problem solving, non-emotional recognition, self-recognition, psychomotor speed, executive functioning, Theory of Mind, verbal list learning and digit span performance. More severe negative symptoms are associated with poorer language fluency, IQ, attention, memory, learning, speed of processing, reasoning, executive functioning, insight, social cognition, and olfaction. More severe disorganised symptoms are associated with poorer IQ, attention, executive functioning, speed of processing, reasoning/problem solving, and memory, but not verbal working memory. Thought disorder was associated with poorer semantic priming and verbal fluency.

March 2022

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Positive symptoms are a well-documented feature of schizophrenia and are arguably the most recognisable and conspicuous symptoms. Positive symptoms include hallucinations and delusions. Hallucinations are defined as a perceptual experience that occurs in the absence of any external sensory input, and are most commonly auditory, but can occur in any modality. Delusions are distortions or exaggerations of inferential thinking, which lack any logical consistency, are not explained by cultural beliefs, and persist regardless of contradictory evidence. Persecutory delusions involve the belief that people are “out to get” the individual, resulting in a lack of trust in others. Delusion of reference refers to the belief that neutral events are directed specifically towards the individual. Somatic delusions involve the belief that the individual has a physical ailment contrary to medical advice. Delusions of grandeur are characterised by an exaggerated belief that the individual has power, ability, or fame. Positive symptoms can cause extreme distress for the person. The severity of positive symptoms can significantly affect a person’s day-to-day function, quality of life, and may also be associated with impaired cognitive ability. Positive symptoms have been shown to be more responsive to antipsychotic treatment than other symptom dimensions.

What is the evidence regarding positive symptoms?

Moderate quality evidence finds features of hallucinations are similar across psychiatric conditions, apart from age of onset of hallucinations, which is earlier in non-clinical and dissociative disorder groups (<12 years) than in schizophrenia (late teens to early 20s), and is later in affective disorders, neurological disorders, and alcohol-related conditions (middle or older age). The prevalence of visual hallucinations in people with schizophrenia is around 27%, and the prevalence of auditory hallucinations is around 59%. These rates are higher than in affective psychosis (visual = 15%, auditory = 28%). They are also higher than general population rates (7%), but lower than in Parkinson’s disease (15-40%), dementia with Lewy bodies (60-90%), age-related eye disease (10-60%), and death-bed visions (50%). In schizophrenia, visual hallucinations are associated with more severe psychopathological profile and less favourable outcomes; they are complex, negative in content, and are interpreted to have personal relevance.

Moderate to high quality evidence finds medium-sized associations between increased maladaptive appraisals and beliefs about voices and increased voice-related and emotional distress. Maladaptive appraisals and beliefs include perceived power, intrusiveness, dominance, malevolence, lack of control, and metaphysical beliefs. Positive appraisals and beliefs about voices showed a small association with reduced distress.

Moderate to high quality evidence finds small to medium-sized relationships between increased paranoia and low self-esteem or increased externalising attributional bias (incorrectly holding others responsible for negative events). Increased paranoia was also associated with seeing others as controlling, dangerous, and rejecting. Compared to controls, people with psychosis and persecutory delusions show a medium-sized effect of more externalising attributional bias, a large effect of low explicit (conscious) self-esteem, and a small to medium-sized effect of low implicit (unconscious) self-esteem. Compared to people with depression, people with psychosis and persecutory delusions show a large effect of more externalising attributional bias, a large effect of more explicit self-esteem, with no differences in implicit self-esteem. Compared to people with psychosis without persecutory delusions, people with psychosis and persecutory delusions show a medium-sized effect of more externalising attributional bias, with no differences in explicit or implicit self-esteem.

High quality evidence finds a medium-sized association between more severe delusions and more belief inflexibility. There were medium to large effects of more jumping to conclusions, bias against disconfirmatory or confirmatory evidence, and more liberal acceptance in people with schizophrenia with current delusions compared to controls or people with schizophrenia who do not experience delusions. There was also a medium-sized relationship between poor insight (overall unawareness of having a mental disorder) and increased reality distortion.

Moderate to high quality evidence found a small effect of increased positive symptoms in people with schizophrenia and current cannabis use compared to people with schizophrenia and no cannabis use. Moderate to high quality evidence found no differences in positive symptoms between people with schizophrenia who recently abstained from cannabis use compared to people with schizophrenia and no cannabis use.

February 2022

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Schizophreniform disorder is a part of the schizophrenia spectrum of disorders and has sometimes been used as a provisional diagnosis while waiting to see if symptoms improve by six months or progress, resulting in a diagnosis of schizophrenia. DSM-5 requires at least one of the following symptoms is present for a significant portion of the time during a one-month period, but for less than six months: delusions, hallucinations or disorganised speech. Disorganised behaviour or negative symptoms may also be present. There can be no manic, depressive or mixed manic-depressive episodes, and any mood disturbance must have been present for  minority of the time. The symptoms cannot be due to the effects of a substance or due to a medical or neurological disorder.

What is the evidence for schizophreniform disorder?

Moderate to high quality evidence suggests the rate of a schizophrenia diagnosis following a diagnosis of schizophreniform disorder is around 65% by about four years. The rate of first-episode psychosis patients retaining a diagnosis of schizophreniform disorder over time is around 29%.

February 2022

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Schizoaffective disorder is on the schizophrenia spectrum of illnesses. Diagnosis of schizoaffective disorder requires schizophrenia-like symptoms of psychosis, in addition to affective/mood symptoms such as depression. There is some debate as to whether schizoaffective disorder represents a unique diagnosis or an intermediary between schizophrenia and mood disorders. There are also considerable differences between different diagnostic criteria regarding the definition of schizoaffective disorder; particularly the Diagnostic and Statistical Manual (DSM) and the International Classification of Diseases (ICD) criteria. Specifically, the ICD and also the Research Diagnostic Criteria (RDC) require simultaneous and equally prominent presence of psychotic and affective symptoms; conversely, the DSM requires an additional period (>2 weeks) where the psychotic symptoms alone are present.

What is the evidence relating to schizoaffective disorder diagnosis?

Moderate to low quality evidence suggests schizoaffective disorder occupies an intermediary position between schizophrenia and mood disorders, but is not clearly distinct from either disorder.

Moderate quality evidence found people diagnosed with schizoaffective disorder using RDC/ICD criteria may have had fewer hospitalisations, are more likely to be male, and are more likely to be older or married than people diagnosed using DSM IIIR/IV criteria. Compared to people with schizophrenia, people with schizoaffective disorder may be more likely to be male, Caucasian, married, have a longer duration of illness, have lower levels of functioning, more depression, and more negative symptoms. Compared to people with bipolar disorder, people with schizoaffective disorder may be younger, have an earlier age at onset, fewer years of education, not Caucasian or African American, never married, have a longer duration of illness, more positive and negative symptoms, more depression, and higher IQ.

Around 36% of people initially diagnosed with schizoaffective disorder have their diagnosis changed at the second assessment. Conversely, around 55% of people diagnosed with schizoaffective disorder at the second assessment were originally diagnosed with other disorders. Schizophrenia or affective disorders were the most common original or subsequent diagnosis.

February 2022

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