# Schizophrenia spectrum & other psychotic disorders The curriculum's fourth named type. Psychosis = a break with shared reality: delusions, hallucinations, disorganisation. The counselor's role is detection, family psychoeducation, and referral, not solo management. **If someone is hearing voices or believing things that frighten them:** stay calm, keep them safe, and take them to a hospital psychiatric service, or call [1166](tel:1166) or [1660 012 1600](tel:16600121600). This is an illness that treatment helps; it is not a curse or a punishment. **A worked example:** A 22-year-old named Bishal has started whispering to himself and says his neighbors are plotting against him. - His family hides him indoors, fearing the "paagal" label - His counselor recognizes that hearing culturally sanctioned voices alone is not psychosis, but the decline in functioning and the disorganized speech are flags - The counselor makes an urgent referral, keeps Bishal's dignity intact, and begins family psychoeducation about the difference between spiritual experience and illness ## Schizophrenia ### Positive symptoms: added to experience - **Delusions**: fixed false beliefs (persecution, reference, grandeur, control) - **Hallucinations**: perceptions without stimulus; hearing voices is the classic - **Disorganised speech**: derailment, incoherence, "word salad" - **Grossly disorganised or catatonic behaviour** ### Negative symptoms: subtracted from experience - **Diminished emotional expression**: flat affect, monotone - **Avolition**: loss of motivated, purposeful activity - Alogia (poverty of speech) · anhedonia · asociality - Negative symptoms predict long-term disability more than positive ones DSM-5 Criteria 1. **2 or more of 5**, each present a significant portion of one month (less if treated), and at least one must be (1), (2), or (3): delusions · hallucinations · disorganised speech · grossly disorganised/catatonic behaviour · negative symptoms. 2. Functioning (work, relationships, self-care) markedly below the level before onset. 3. Continuous signs for at least **6 months**, including ≥1 month of active symptoms (may include prodromal/residual periods). 4. Schizoaffective disorder and mood disorder with psychotic features ruled out. 5. Not attributable to a substance or medical condition. 6. If autism or a childhood communication disorder is present, prominent delusions or hallucinations ≥1 month are also required. Cousins on the spectrum: **Brief psychotic disorder** (298.8/F23): ≥1 day, <1 month, full return, often after acute stress (including postpartum). **Schizophreniform**: schizophrenia picture, 1–6 months. **Delusional disorder** (297.1/F22): delusions ≥1 month with otherwise preserved functioning. **Schizoaffective**: schizophrenia criteria plus major mood episodes, with ≥2 weeks of psychosis without mood symptoms. International Lifetime prevalence ~0.3–0.7% in every population studied; onset typically late teens to early 30s, earlier in men. A famous WHO cross-national finding: outcomes were often *better* in lower-income countries; family involvement and social reintegration appear protective (later re-analyses have contested how general this finding is). Nepal Stigma is the central fact: "paagal" labels, hidden family members, and in the worst cases chaining; plus years of dhami-jhankri treatment before any clinical contact. The National Mental Health Survey 2020 found schizophrenia-spectrum disorders in 0.1% of adults currently (0.2% lifetime). See [Nepal in numbers](https://manoatlas.com/data.md). Hearing culturally sanctioned voices (a deceased relative during mourning, deity communication in trance for a jhankri) is *not* psychosis; the flags are decline in functioning, disorganisation, and distress. First contact is often the counselor's: your jobs are early detection, urgent psychiatric referral, family psychoeducation, and protecting the client's dignity and safety. Two kinds of symptom, two kinds of misunderstanding. Positive symptoms frighten the family; negative symptoms get mistaken for laziness. Psychoeducation that names both is the counselor's most useful hour in a psychosis household. A skill to try · two minutes **For families: steady the everyday.** Recovery leans on rhythm: regular sleep, meals at usual times, one shared simple task (shelling peas, folding clothes), and a calm, low-criticism home voice. Argue with the illness never, with the person never; keep the routine and the warmth. A coping skill, not a treatment: it supports care, it does not replace it. Key points 1. Psychosis is a break with shared reality: delusions, hallucinations, disorganised thinking. 2. It is an illness that medicines and family support treat; it is not possession, karma or a curse. 3. The counselor's job is early detection, family psychoeducation and referral, never solo management. Learn more Pick one, not all: these are chosen to be light, not exhaustive. Video · 5 min[What is schizophrenia? (TED-Ed, Anees Bahji)](https://www.youtube.com/watch?v=K2sc_ck5BZU): Positive/negative symptoms in five calm minutes. Article[WHO fact sheet: Schizophrenia](https://www.who.int/news-room/fact-sheets/detail/schizophrenia); Includes the human-rights and stigma angle relevant to Nepal. Book**The Center Cannot Hold (Elyn Saks)**: A law professor's memoir of living with schizophrenia. --- *Source: https://manoatlas.com/psychosis · Licence: CC BY-NC-SA 4.0. Mano Atlas is an educational resource, not a diagnostic tool.*