Presentation on theme: "Assessment and Differential Diagnosis of Abnormal Experience"— Presentation transcript:
1Assessment and Differential Diagnosis of Abnormal Experience Illuminating Psychosis Demian Rose, MD, PhD, U.C. San Francisco Prodrome Assessment Research and Treatment (PART) ProgramAssessment and Differential Diagnosis of Abnormal Experience
2Goals Describe psychosis as a clinical phenomenon Discuss clinical pearls that will help you to distinguish between types of abnormal experienceDevelop differentiation of psychosis by time course and co-morbidities
3Chronic PsychosisOften develops slowly, during adolescence and young adulthoodEarly on, shares many Sx with other psychiatric disordersEventually leads to significant morbidity and mortalityAs everyone here understands, the challenges we face
4Chronic Psychosis Begins slowly Emerges non-specifically Relates to subjective experience of self
5How best to diagnose90% of people who have a parent with schizophrenia will not develop the disorder; 1/3 of all people diagnosed with schizophrenia have no family historyLaboratories and imaging are often only minimally helpfulClinical Interview is Important!
7Psychosis MythsChronic psychosis is a return to a core, primitive level of brain processingChronic psychosis is a cliff: once you fall over it, you can never get backChronic psychosis is an understandable reaction to society or parents7
8Clinical Challenge Balancing two factors: Subjective patient experienceSpecificity of symptom presentationI think we’ve focused too much on the latter, maybe because we see psychosis as this cliff or separate processBut research over the past ten years suggests we can ask subjective experience questions that are specific enough to stratify risk for the development of chronic psychosis
9Psychosis Hallucinations Delusions or Paranoia Disorganization CatatoniaOperatively defined as a problem with reality testing, although that’s a pretty broad category.
10HallucinationsHallucination = a sensory experience that occurs in the absence of a stimulusIllusion: a sensory experience that misinterprets a stimulus
15Delusional Thinking“Did that one stupid scene from ‘The Passion of the Christ’ really do this to me – turn me into a f*&*ing baby? Simon is awesome because he believes I’m evil, like I believe I’m evil and he forgives me.”
16ParanoiaParanoia = suspiciousness and mistrust that occur out of proportion to reality
21Disorganized Thinking “Where do my thoughts end and my feelings begin? Will I ever get over this sickness? Will I ever have an uncorrupt ego? No, then I’d be God. Do I care about God? Why do I care about God?”
23Clinically Useful Concepts: Positive SymptomsMost specific for predicting psychosisNegative SymptomsMildly correlated with chronic prognosisCognitive SymptomsStrongly correlated with chronic prognosisPositive symptoms tend to have an identifiable start date, others usually present from early on and continue to progress.The course of symptom domains overlaps, but is not identical.In contrast to positive symptoms, which begin at a certain point in life, some degree of negative symptoms, and most cognitive symptoms are present from early life.Each domain gets worse during acute episodes.There may not be a return to the previous baseline after each episode, although there is some evidence that positive symptoms may become less acute later in life.DeQuardo JR: Pharmacologic treatment of first-episode schizophrenia: early intervention is the key to outcome. J Clin Psychiatry 1998; 59 (suppl 19):9-17We often hear about cognitive deficits in schizophrenia, but maybe don’t give them the attention they deserve in terms of thinking critically about how they differ from other types of cognitive deficit. For example, people with schizophrenia have overall slightly lower IQ than population mean, but vastly decreased functioning. And yet, we say cognitive deficits are the best correlate of that poor functioning. So, what are we talking about?
24Diagnosis The basics: Primary vs. Secondary Other Symptoms Symptom Time Course
25Differential Dx of Psychosis Secondary Psychotic DisordersSubstance induced psychotic disorderPsychosis secondary to a general medical conditionDeliriumDementiaPsychosis secondary to a mood disorderSecondary psychotic disorders are those in which psychosis occurs as a result of some other diagnosable condition, such as intoxication, seizure disorder, or a cognitive disorder.
26Differential Diagnosis of Psychosis Mood DisordersBipolar I disorder, manic episodeMajor depression with psychotic featuresAffective disorders may also include psychotic symptoms during periods of active mood disturbance.Prominent psychosis outside a period of mood disturbance should be classified as schizoaffective disorder.
27Differential Diagnosis of Psychosis Primary Psychotic DisordersSchizophreniaSchizoaffective disorderBrief psychotic disorderDelusional disorderPsychosis is a syndrome, not a diagnosis, and may occur in a number of disorders.Primary psychotic disorders are those in which psychosis is one of the core features of the disorder.
28The Real IssueForgetting for a moment the problems with categorical diagnoses, who is the DSM-IV criteria meant to rule in and who is it meant to rule out?If you were to explain to a family member why someone has a diagnosis of a primary psychotic disorder, how would you do so?
30Schizophrenia: “definition” Schizophrenia is a chronic or recurrent disorder characterized bySustained periods of psychosisDSM = at least one monthLong-term functional deteriorationDSM = at least six monthsThe current concept of schizophrenia includes two basic elements: psychosis and deterioration in the basic domains of functioning, such as self-care, independent living, interpersonal relations, productivity, and recreation.
31Schizophrenia: Diagnosis Two or more Criterion A Sx:hallucinationsdelusionsdisorganized speechdisorganized/catatonic behavior“negative symptoms”Flat affect, lack of motivation, social withdrawalWhen can you have just one Criterion A symptoms and still be diagnosed with schizophrenia? As a class, the psychotic disorders share the one or usually all of the Criterion A symptoms – what differs is severity or the natural history
32Psychotic Timelines Brief Psychotic Disorder At least one Criterion A SxAt least one day but less than one month of functional disturbance
33Other “schizos” Schizophreniform At least one Criterion A Sx At least one month, but less than six months of functional deterioration
34Other psychotic syndromes Delusional DisorderAt least one month“Non-bizarre”No other psychotic SxImpairment related specifically to delusion
36yes yes no yes no no Criterion A Sx and 6 mo dysfunction? Simultaneously meet criteria for mood disordes?Schzioaffective DisorderSchizophreniaProminent Delusions?Delusional DisorderPsychosis NOSChronic Primary PsychosisSpecifiersDiagnosisyesyesnoyesnono
37yes no Between 1 day and 1 mo Sx with full recovery Brief Psychotic DisorderPsychosis NOSBrief Primary PsychosisDiagnosisyesno