DSM-IV TR Schizophrenia & Other Psychotic Disorders

1. DSM-IV TRSchizophrenia & Other Psychotic Disorders Siva Devarajan Associate Professor of Psychiatry University of Western Ontario

2. 295.XX Schizophrenia .30 Paranoid Type .10 Disorganized Type .20 Catatonic Type .90 Undifferentiated Type .60 Residual type 295.40 Schizophreniform Disorder 295.70 Schizoaffective Disorder 297.1 Delusional Disorder 298.8 Brief Psychotic Disorder 297.3 Shared Psychotic Disorder 293.XX Psychotic Disorders due to GMC .81 with Delusions .82 with Hallucinations (. . .)Substance induced Psychotic Disorders (Refer to substance specific codes) 298.9 Psychotic Disorders NOS DSM-IV TR Schizophrenia & Other Psychotic Disorders

3. Psychotic Symptoms • Presence of Delusions and Hallucinations • Severely disorganized behavior, speech and thought • Also occurs in Mood Disorders • May be associated with substance use • May be due to medication side effects • May be due to Delirium, GMC DSM-IV TR

4. DSM-IV-TR Criteria for Schizophrenia 295.XX A – Characteristic symptoms - *two or more of the following, one month, less if treated: • Delusions • Hallucinations • Disorganized Speech • Disorganized or Catatonic Behavior • Negative symptoms B – Social/Occupations Dysfunction *One or more areas of functioning, work, self care or interpersonal relationship. C – Duration • continuous signs of disturbance for six months • Continuous criteria for a month, less if treated • May also include Prodromal / residual symptoms

5. DSM-IV-TR Criteria for Schizophrenia (Cont’d) D – Schizoaffective and mood disorder exclusion - if present, duration is very brief E – Substance and GMC exclusion F – Relationship to PDD - Diagnosis of schizophrenia made if criteria A is met.

6. DSM-IV-TR Diagnostic Criteria for Schizophrenia Classification of Longitudinal course (at least one year has elapsed since the initial onset) • Episodic with Interepisode Residual symptoms • As above, with prominent negative symptoms • Episodic with no interepisode residual symptoms • Continuous with or without negative symptoms • Single episode – Full/partial remission • Single episode - with or without negative symptoms • Other or unspecified pattern DSM-IV-TR

7. Subtypes of Schizophrenia • Pure types are less common • Mixtures of symptoms more common • Catatonic type – rare • Disorganized type *speech, behavior, affect • Paranoid type *diagnosis of exclusion • Undifferentiated type • Residual type

8. Case Study • Young female, poor functioning • Lives with parents, unemployed • Two previous hospitalizations • Antipsychotics recently reduced • Can control behavior of others • Others can read her mind and being watched • Multiple voices, threatening in nature • Low energy, motivation, unable to think • Unable to care for herself • Depressed, decreased appetite and sleepDSM-IV-TR

9. Enemy knew her thoughts She could control other people’s activities Thoughts were “stopping in mid stream” Mind was “going blank” Felt listless, depressed, unable to concentrate Social contacts parents and boyfriend Symptoms responded to Trifluoperazine readmitted following non-compliance Overtly suspicious Felt threatened by voices Sad, exhausted, unable to enjoy anything Chronically apprehensive “incapable of working” Symptoms responded to Trifluoperazine Returned home with parents Switched to Risperidone as an outpatient DSM-IV-TR Case Study (Cont’d)

10. DSM-IV-TR Diagnosis Axis I – 295.30 – Schizophrenia, Paranoid type Interepisode Residual Symptoms Depressive Disorder – NOS Axis II – V71.09 – No diagnosis Axis III – None Axis IV - ? Less contact with BF Axis V – GAF 30 DSM-IV-TR

11. DSM-IV-TR Criteria for Schizophreniform Disorders A Criteria A, D and E of schizophrenia are met B Episode last *one month to six months (provisional or not). - without good prognostic features - with * good Prognostic features (two or more) • Absence of blunted or flat effect • Good premorbid features • Confusion on perplexity at the height of episode • *onset of psychotic symptoms within 4 weeks ( behavior or functioning). DSV-IV-TR

12. 30 year old lawyer – Disheveled, hypervigilant, easily startled. Seems to be responding to voices. Has been well until 3 months ago. Excellent vocational and social activity. GF broke up recently, began to follow her. Problems with attendance, punctuality, productivity. Criticized by his boss. Thought he was unduly criticized and humiliated. Voices “faggot”, “a jerk off”. Convinced office staff were scheming against him. Believed his life was in danger. Considered buying a gun/police protection. Depressed, poor sleep, no biological features. Not hyperactive, energetic or expansive mood. No H/O substance use/GMC. Responded to treatment as an inpatient. DSM-IV TR Case History

13. DSM-IV-TR Diagnosis Axis I 295.40 Schizophreniform disorder – Good prognosis two features Axis II V71.09 No diagnosis. Axis III None Axis IV Breakup with girlfriend Axis V GAF 30 Admission GAF 60 Discharge GAF 90 Highest level past year Differential Diagnosis: • Schizophrenia • Depression with psychotic symptoms • Brief psychotic disorder • Psychosis due to GMC/substance use DSM-IV TR

14. Schizoaffective Disorder DSM-IV-TR Criteria 295.75 • An uninterrupted period of illness with MDE, Manic Episode or mixed Episode with criteria A for schizophrenia. • *Delusions or Hallucinations for two weeks in the absence of prominent mood symptoms. • Criteria for a mood episode are present, during the active and residual phase of the illness. • Not due to effects of substance or GMC. Specify Type Bipolar Type • Disturbance includes Manic or Mixed Episode or Depressive episode. Depressive Type - Disturbance only include MDE DSM-IV-TR

15. 26 year old female bank officer No relevant family, past or medical history Separated from husband for 4 months Brother was jailed a month ago. Moved in with her parents a month ago. Gradual deterioration in her functioning. Found in a “confused” state in a railway station. Agitated, hallucinating with marked thought disorder Voices making comments about her. Command hallucinations to kill herself. Hospitalized and treated with antipsychotics. Discharged c/o mother with follow up. Readmitted after 6 months. Anxiety, insomnia and auditory hallucinations. - Convinced mother was going to hurt her. TV is controlling her, others can read her mind. Also, prominent manic symptoms for 3 wks. Shopping sprees, not sleeping, pacing for much of the night. Convinced that God, too, was talking to her. Someone was touching and arousing her sexuality. Hardly slept for 3 nights prior to admission. Hyperactive, disruptive, excites and irritable. Hypersexual, convinced she would heal everyone. Treated with Fluphenazine & Lico3. Improved within the next 6 months. DSM-IV-TR Schizoaffective Disorder – Case Study

16. DSM-IV-TR Diagnosis Axis I Schizoaffective Disorder – Bipolar Type Axis II V71.09 No diagnosis Axis III None Axis IV Brother in jail, separation from husband Axis V GAF = 30 upon admission GAF = 70 upon discharge DSM-IV TR

17. Differential Diagnoses • Schizoaffective Disorder least reliable diagnosis in DSM-IV. • ?Mood symptoms are of sufficient duration and severity. • Mood Disorder with Psychotic features. • Schizophrenia. • Brief Psychotic Disorder. • Schizophreniform Disorder • Due to substance use/GMC. DSM-IV TR

18. Delusional Disorder DSM-IV-TR Diagnostic Criteria 297.1 A Nonbizarre delusions (involving situations that occur in real life) of at least one month duration. B *Criterion A for Schizophrenia has never been met. C Functioning or behavior not markedly impaired. D If mood episodes have occurred, they are brief. E Not related to effects of substances or GMC. Specify Type: - Eratomanic Type - Somatic Type - Grandoise Type - Mixed Type • Jealous Type - Unspecified Type • Persecutory Type DSM-IV TR

19. Differential Diagnosis of Delusional Disorder *For several reasons, diagnosis is much harder. Over valued ideas Obsessive Compulsive Disorder Social Phobia Hypochondriasis May be part of cultural or religious system May be part of other Psychotic disorder Related to Substance use Related to GMC Mood Disorder with Psychotic symptoms Paranoid Personality Disorder DSM-IV-TR

20. 39 year old woman referred by a Dermatologist No objective evidence of skin disease. Patient insists she is plagued with insects. 12 years of infestation, skin itch, spread all over her body Convinced itch is due to bugs. Feel them under the skin, feel pain from bites. Has seen several physicians over last 12 years. Distressed and angry no one has been able to help. Washed her skin very frequently. Resorted to assorted applications including bleach. Few serious overdoses as she felt so wretched. Stopped work, withdrew socially, sleeps very poorly. Convinced people are avoiding her because she is dirty. Agitated and totally preoccupied with bugs. Otherwise charming and engaging, converse intelligently. No other psychotic or Mood symptoms. DSM-IV-TR Delusional Disorder – Case Study

21. DSM-IV-TR Diagnosis Axis I 297.1 Delusional Disorder, Somatic Type 311 Depressive Disorder NOS Axis II V71.09 No Diagnosis Axis III None Axis IV Social Isolation, Inability to work Axis V GAF = 30 (current) GAF = 40 (Highest in past year) DSM-IV-TR

22. Brief Psychotic Disorder • Has replaced “Brief Reactive Psychoses” • Duration less than a month, at least a day. • Result of a stressor or not • Not related to Mood Disorder, substance use, GMC • Associated with Good Premorbid Functioning • Associated with a Good Prognosis. • It is a “retrospective” diagnosis • If in doubt, Psychotic Disorder NOS. DSM-IV-TR

23. Brief Psychotic Disorder DSM-IV-TR Diagnostic Criteria 298.8 A Presence of ONE or more of the following: 1. Delusions 2. Hallucinations 3. Disorganized Speech 4. Disorganized on Catatonic Behavior B Duration of Disturbance one day to one month Eventual full return to premorbid functioning C Not related to Schizophrenia, Schizoaffective Disorder, Mood Disorder, Substance us or GMC. Specify: with marked stressors without marked stressors with Post partum onset (within 4 weeks postpartum) DSM-IV-TR

24. DSM-IV-TR Diagnostic Criteria for Shared Psychotic Disorders – 297.3 • A delusion develops in an individual in the context of a close relationship with another person who is already has an established delusion. • The delusion is similar in context. • Not better accounted for by another Psychotic disorder, Mood Disorder OR Direct effect of a substance. DSM-IV-TR

25. DSM-IV-TR Diagnostic Criteria for Psychotic Disorder due to GMC-293.xx • Prominent Hallucinations OR Delusions • Evidence form History, Physical Examination of Laboratory Findings. • Not better accounted for by another mental disorder • Does not occur EXCLUSIVELY during a course of a delirium Code based on predominant symptom: • 81 with delusions • 82 with hallucinations (Name of GMC in Axis I AND the GMC in Axis III (use ICD-9-CM Code) Example: Axis I- 293.81 Psychotic Disorder due to Ca Lung with Delusions Axis III- Ca Lung

26. Substance Induced Psychotic Disorders DSM-IV-TR Diagnostic Criteria A Prominent Hallucinations or Delusions (do not include if the patient has insight). B History, Examination or laboratory finding 1. Symptoms in Criteria A developed during or within a month of Intoxication/withdrawal. 2. Medication use is related to disturbance. C Disturbance is NOT better accounted for by a Psychotic Disorder that is NOT substance induced. D Disturbance does not occur exclusively during a course of Delirium. Code for Specific Substance: 291.5 Alcohol, with delusions. Specify: 291.3 Alcohol, with hallucations with onset during Intoxication 292.11 Cannabis, with delusions with onset during withdrawal 292.12 Cannabis, with hallucinations DSM-IV-TR

27. Differential Diagnosis – Substance induced Psychosis • Delirium • Substance intoxication ONLY • Substance withdrawal ONLY • Psychotic symptoms may NOT be substance induced 1. Symptoms predates substance use. 2. Symptoms persist after intoxication/withdrawal (usually 4 weeks) 3. Not related to type or amount of substance used. 4. Family history of Primary Psychotic Disorder • Dual Diagnoses • Recurrent flashbacks involving LSD • Substance may precipitate symptoms in “vulnerable patients” DSM-IV-TR

28. DSM-IV-TR Criteria for Psychotic Disorders Nos.-298.9 • Psychotic symptomology • Inadequate information to make specific diagnosis • Contradictory information • Symptoms do not meet criteria for ANY specific Psychotic Disorder • Multiple examples: 1)Delusions with periods of overlapping ME 2) Post Partum Psychosis 3) Psychotic Disorders with less than one month duration with no remission 4) Psychotic Disorder with unknown etiology 5) Persistent Auditory Hallucinations DSM-IV-TR