Secondary psychotic syndrome, with delusions

Essential (Required) Features:

• All diagnostic requirements for Secondary Psychotic Syndrome are met.
• The presentation is characterized by prominent delusions without prominent hallucinations.

Boundary with other disorders and normality:

• Boundary with Schizophrenia or Other Primary Psychotic Disorders: Determining whether psychotic symptoms are due to a medical condition as opposed to manifestations of a primary mental disorder is often difficult because the clinical presentations may be similar. Establishing the presence of a potentially explanatory medical condition that can cause hallucinations or delusions and the temporal relationship between the medical condition and the psychotic symptoms is critical in diagnosing Secondary Psychotic Syndrome. A list of medical conditions that have been reported to cause psychotic symptoms is included below (p. _), but the strength of the association varies according to the medical condition. Secondary Psychotic Syndrome is often characterized by clinical features that would be atypical for a Primary Psychotic Disorder such as later age of onset, rapid occurrence of clouding of consciousness, and accompanying cognitive, neurological, or medical symptoms. In Secondary Psychotic Syndrome, disorganized thinking (formal thought disorder) is not typically present, delusions are more often simple and fragmented, and hallucinations are more often visual, tactile, olfactory or gustatory rather than auditory.
• Boundary with psychotic symptoms that are precipitated by the stress of being diagnosed with a medical condition: Depending on the nature of the medical condition (e.g., a life-threatening type of cancer, a potentially fatal infection) or its onset (e.g., a heart attack, a stroke, a severe injury), being diagnosed with a severe medical condition can be experienced as a traumatic event, which could trigger the development of psychotic symptoms (e.g., hallucinations and delusions) in susceptible individuals (e.g., individuals with a pre-existing Psychotic Disorder, a Dissociative Disorder, or a Personality Disorder). If the psychotic symptoms are part of the presentation of a diagnosable mental disorder that is judged to be precipitated or exacerbated by the stress of being diagnosed or coping with a medical condition, the appropriate mental disorder (e.g., Acute and Transient Psychotic Disorder, Post-Traumatic Stress Disorder, Recurrent Depressive Disorder) should be diagnosed rather than Secondary Psychotic Syndrome.
• Boundary with Delirium Due to Disease Classified Elsewhere: Hallucinations or delusions can occur in the context of Delirium Due to Disease Classified Elsewhere. Delirium is characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day, accompanied by other cognitive impairments such as memory deficit, disorientation, or impairment in language, visuospatial ability, or perception. Disturbed attention and awareness and severe cognitive impairment are not features of Secondary Psychotic Syndrome. If the psychotic symptoms are judged to be better explained by Delirium Due to Disease Classified Elsewhere, an additional diagnosis of Secondary Psychotic Syndrome is not warranted.
• Boundary with Dementia: Hallucinations or delusions can occur in the context of Dementia, which is characterized by a decline from a previous level of cognitive functioning with impairment in two or more cognitive domains (such as memory, executive functions, attention, language, social cognition and judgment, psychomotor speed, visuoperceptual or visuospatial abilities). In contrast, Secondary Psychotic Syndrome is not accompanied by marked cognitive impairment. The presence of hallucinations or delusions in the context of Dementia can be recorded using the Behavioural or Psychological Disturbances in Dementia qualifier for Psychotic Symptoms in Dementia. If the psychotic symptoms are judged to be due to the same medical condition as is causing the Dementia, an additional diagnosis of Secondary Psychotic Syndrome is not warranted.
• Boundary with psychotic symptoms caused by substances or medications, including withdrawal effects: When establishing a diagnosis of Secondary Psychotic Syndrome, it is important to rule out the possibility that a medication or substance is causing the hallucinations or delusions instead of or in addition to the etiological medical condition. This involves first considering whether any of the medications being used to treat the medical condition are known to cause psychotic symptoms at the dose and duration at which it has been administered. Second, a temporal relationship between the medication use and the onset of the psychotic symptoms should be established (i.e., the psychotic symptoms began after administration of the medication and/or remitted once the medication was discontinued). The same reasoning applies to individuals with a medical condition and psychotic symptoms who are also using a psychoactive substance known to cause hallucinations or delusions, either in the context of intoxication or withdrawal (e.g., visual hallucinations during Sedative, Hypnotic or Anxiolytic withdrawal; paranoid delusions during Cocaine Intoxication). In such cases, if the intensity or duration of the psychotic symptoms is substantially in excess of psychotic-like disturbances of perception, cognition, or behaviour that are characteristic of the substance-specific Intoxication or Withdrawal syndromes, then Substance-Induced Psychotic Disorder is the appropriate diagnosis, applying the appropriate category corresponding to the substance involved.

Potentially Explanatory Medical Conditions (examples):

Brain disorders and general medical conditions that have been shown to be capable of producing psychotic syndromes include:

• Diseases of the Nervous System (e.g., encephalitis, encephalopathy, genetic Creutzfeldt-Jakob disease, intracerebral hemorrhage, Lewy body disease, migraine, Movement Disorders such as Huntington disease or Friedreich ataxia, multiple sclerosis, seizures, stroke)
• Certain Infectious or Parasitic Diseases (e.g., neurosyphilis)
• Diseases of the Immune System (e.g., systemic lupus erythematosus)
• Endocrine, Nutritional or Metabolic Diseases (e.g., hyper- and hypoadrenalism, hyper- and hypoparathyroidism, hyper- and hypothyroidism, hypo-osmolality or hyponatraemia, hypoglycaemia, porphyrias, vitamin B1 or vitamin B12 deficiency, Wilson disease)
• Injury, Poisoning or Certain Other Consequences of External Causes (e.g., brain injury, concussion, traumatic haemorrhage, injury of optic or acoustic nerve)
• Neoplasms (e.g., neoplasms of brain or meninges)