Presentation on theme: "DSM-IV TR Schizophrenia & Other Psychotic Disorders"— Presentation transcript:
1DSM-IV TR Schizophrenia & Other Psychotic Disorders Siva DevarajanAssociate Professor of PsychiatryUniversity of Western Ontario
2Schizophrenia & Other Psychotic Disorders 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 NOSDSM-IV TR295.XX Schizophrenia.30 Paranoid Type.10 Disorganized Type.20 Catatonic Type.90 Undifferentiated Type.60 Residual typeSchizophreniform DisorderSchizoaffective Disorder297.1 Delusional Disorder298.8 Brief Psychotic Disorder297.3 Shared Psychotic Disorder
3Psychotic Symptoms Presence of Delusions and Hallucinations Severely disorganized behavior, speech and thoughtAlso occurs in Mood DisordersMay be associated with substance useMay be due to medication side effectsMay be due to Delirium, GMCDSM-IV TR
4DSM-IV-TR Criteria for Schizophrenia 295.XX A – Characteristic symptoms - *two or more of the following, one month, less if treated:DelusionsHallucinationsDisorganized SpeechDisorganized or Catatonic BehaviorNegative symptomsB – Social/Occupations Dysfunction*One or more areas of functioning, work, self care or interpersonal relationship.C – Durationcontinuous signs of disturbance for six monthsContinuous criteria for a month, less if treatedMay also include Prodromal / residual symptoms
5DSM-IV-TR Criteria for Schizophrenia (Cont’d) D – Schizoaffective and mood disorder exclusion- if present, duration is very briefE – Substance and GMC exclusionF – Relationship to PDD- Diagnosis of schizophrenia made if criteria A is met.
6DSM-IV-TR Diagnostic Criteria for Schizophrenia Classification of Longitudinal course (at least one year has elapsed since the initial onset)Episodic with Interepisode Residual symptomsAs above, with prominent negative symptomsEpisodic with no interepisode residual symptomsContinuous with or without negative symptomsSingle episode – Full/partial remissionSingle episode - with or without negative symptomsOther or unspecified patternDSM-IV-TR
7Subtypes of Schizophrenia Pure types are less commonMixtures of symptoms more commonCatatonic type – rareDisorganized type *speech, behavior, affectParanoid type *diagnosis of exclusionUndifferentiated typeResidual type
8Case Study Young female, poor functioning Lives with parents, unemployedTwo previous hospitalizationsAntipsychotics recently reducedCan control behavior of othersOthers can read her mind and being watchedMultiple voices, threatening in natureLow energy, motivation, unable to thinkUnable to care for herselfDepressed, decreased appetite and sleep DSM-IV-TR
9Case Study (Cont’d) Enemy knew her thoughts She could control other people’s activitiesThoughts were “stopping in mid stream”Mind was “going blank”Felt listless, depressed, unable to concentrateSocial contacts parents and boyfriendSymptoms responded to Trifluoperazinereadmitted following non-complianceOvertly suspiciousFelt threatened by voicesSad, exhausted, unable to enjoy anythingChronically apprehensive “incapable of working”Symptoms responded to TrifluoperazineReturned home with parentsSwitched to Risperidone as an outpatientDSM-IV-TR
10Axis I – 295.30 – Schizophrenia, Paranoid type DSM-IV-TR DiagnosisAxis I – – Schizophrenia, Paranoid typeInterepisode Residual SymptomsDepressive Disorder – NOSAxis II – V71.09 – No diagnosisAxis III – NoneAxis IV - ? Less contact with BFAxis V – GAF 30DSM-IV-TR
11DSM-IV-TR Criteria for Schizophreniform Disorders A Criteria A, D and E of schizophrenia are metB 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 effectGood premorbid featuresConfusion on perplexity at the height of episode*onset of psychotic symptoms within 4 weeks ( behavior or functioning).DSV-IV-TR
12Case History 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 TR30 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.
13DSM-IV-TR DiagnosisAxis I Schizophreniform disorder – Good prognosis two featuresAxis II V71.09 No diagnosis.Axis III NoneAxis IV Breakup with girlfriendAxis V GAF 30 AdmissionGAF 60 DischargeGAF 90 Highest level past yearDifferential Diagnosis:SchizophreniaDepression with psychotic symptomsBrief psychotic disorderPsychosis due to GMC/substance use DSM-IV TR
14Schizoaffective Disorder DSM-IV-TR CriteriaAn 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 TypeBipolar TypeDisturbance includes Manic or Mixed Episode or Depressive episode.Depressive Type- Disturbance only include MDE DSM-IV-TR
15Schizoaffective Disorder – Case Study - 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-TR26 year old female bank officerNo relevant family, past or medical historySeparated from husband for 4 monthsBrother 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 disorderVoices 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.
16DSM-IV-TR Diagnosis Axis I Schizoaffective Disorder – Bipolar Type Axis II V71.09 No diagnosisAxis III NoneAxis IV Brother in jail, separation from husbandAxis V GAF = 30 upon admissionGAF = 70 upon discharge DSM-IV TR
17Differential 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 DisorderDue to substance use/GMC.DSM-IV TR
18Delusional 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 TypeJealous Type - Unspecified TypePersecutory Type DSM-IV TR
19Differential Diagnosis of Delusional Disorder *For several reasons, diagnosis is much harder.Over valued ideasObsessive Compulsive DisorderSocial PhobiaHypochondriasisMay be part of cultural or religious systemMay be part of other Psychotic disorderRelated to Substance useRelated to GMCMood Disorder with Psychotic symptomsParanoid Personality Disorder DSM-IV-TR
20Delusional Disorder – Case Study 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-TR39 year old woman referred by a DermatologistNo objective evidence of skin disease.Patient insists she is plagued with insects.12 years of infestation, skin itch, spread all over her bodyConvinced 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.
21DSM-IV-TR Diagnosis Axis I 297.1 Delusional Disorder, Somatic Type 311 Depressive Disorder NOSAxis II V No DiagnosisAxis III NoneAxis IV Social Isolation, Inability to workAxis V GAF = 30 (current)GAF = 40 (Highest in past year)DSM-IV-TR
22Brief Psychotic Disorder Has replaced “Brief Reactive Psychoses”Duration less than a month, at least a day.Result of a stressor or notNot related to Mood Disorder, substance use, GMCAssociated with Good Premorbid FunctioningAssociated with a Good Prognosis.It is a “retrospective” diagnosisIf in doubt, Psychotic Disorder NOS.DSM-IV-TR
23Brief Psychotic Disorder DSM-IV-TR Diagnostic Criteria 298.8A Presence of ONE or more of the following:1. Delusions2. Hallucinations3. Disorganized Speech4. Disorganized on Catatonic BehaviorB Duration of Disturbance one day to one monthEventual full return to premorbid functioningC Not related to Schizophrenia, Schizoaffective Disorder, Mood Disorder, Substance us or GMC.Specify: with marked stressorswithout marked stressorswith Post partum onset (within 4 weeks postpartum) DSM-IV-TR
24DSM-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
25DSM-IV-TR Diagnostic Criteria for Psychotic Disorder due to GMC-293.xx Prominent Hallucinations OR DelusionsEvidence form History, Physical Examination of Laboratory Findings.Not better accounted for by another mental disorderDoes not occur EXCLUSIVELY during a course of a deliriumCode based on predominant symptom:81 with delusions82 with hallucinations(Name of GMC in Axis I AND the GMC in Axis III (use ICD-9-CM Code)Example:Axis I Psychotic Disorder due to Ca Lung with DelusionsAxis III- Ca Lung
26Substance Induced Psychotic Disorders DSM-IV-TR Diagnostic CriteriaA Prominent Hallucinations or Delusions (do not include if the patient has insight).B History, Examination or laboratory finding1. 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 IntoxicationCannabis, with delusions with onset during withdrawalCannabis, with hallucinationsDSM-IV-TR
27Differential Diagnosis – Substance induced Psychosis DeliriumSubstance intoxication ONLYSubstance withdrawal ONLYPsychotic symptoms may NOT be substance induced1. 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 DisorderDual DiagnosesRecurrent flashbacks involving LSDSubstance may precipitate symptoms in “vulnerable patients”DSM-IV-TR
28DSM-IV-TR Criteria for Psychotic Disorders Nos.-298.9 Psychotic symptomologyInadequate information to make specific diagnosisContradictory informationSymptoms do not meet criteria for ANY specific Psychotic DisorderMultiple examples:1)Delusions with periods of overlapping ME2) Post Partum Psychosis3) Psychotic Disorders with less than one month duration with no remission4) Psychotic Disorder with unknown etiology5) Persistent Auditory HallucinationsDSM-IV-TR