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Assessment and Differential Diagnosis of Abnormal Experience.

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Presentation on theme: "Assessment and Differential Diagnosis of Abnormal Experience."— Presentation transcript:

1 Assessment and Differential Diagnosis of Abnormal Experience

2 Goals Describe psychosis as a clinical phenomenon Describe psychosis as a clinical phenomenon Discuss clinical pearls that will help you to distinguish between types of abnormal experience Discuss clinical pearls that will help you to distinguish between types of abnormal experience Develop differentiation of psychosis by time course and co-morbidities Develop differentiation of psychosis by time course and co-morbidities

3 Chronic Psychosis Often develops slowly, during adolescence and young adulthood Often develops slowly, during adolescence and young adulthood Early on, shares many Sx with other psychiatric disorders Early on, shares many Sx with other psychiatric disorders Eventually leads to significant morbidity and mortality Eventually leads to significant morbidity and mortality

4 Chronic Psychosis Begins slowly Begins slowly Emerges non-specifically Emerges non-specifically Relates to subjective experience of self Relates to subjective experience of self

5 How best to diagnose 90% of people who have a parent with schizophrenia will not develop the disorder; 1/3 of all people diagnosed with schizophrenia have no family history 90% of people who have a parent with schizophrenia will not develop the disorder; 1/3 of all people diagnosed with schizophrenia have no family history Laboratories and imaging are often only minimally helpful Laboratories and imaging are often only minimally helpful Clinical Interview is Important! Clinical Interview is Important!

6 Psychosis is not: One thing One thing One process One process

7 Psychosis Myths Chronic psychosis is a return to a core, primitive level of brain processing Chronic psychosis is a cliff: once you fall over it, you can never get back Chronic psychosis is an understandable reaction to society or parents

8 Clinical Challenge Balancing two factors: Balancing two factors: Subjective patient experience Subjective patient experience Specificity of symptom presentation Specificity of symptom presentation

9 Psychosis Hallucinations Delusions or Paranoia DisorganizationCatatonia

10 Hallucinations Hallucination = a sensory experience that occurs in the absence of a stimulus –Illusion: a sensory experience that misinterprets a stimulus

11 Hallucinations WhoWhatWhenWhereHow

12 Hallucinations “Why is it when I hear someone ask ‘are you finished’ that it’s a voice talking down to me? That voice should be talking across to me – it isn’t better than me.” “Why is it when I hear someone ask ‘are you finished’ that it’s a voice talking down to me? That voice should be talking across to me – it isn’t better than me.”

13 Delusional Thinking Delusion = a fixed, false belief that resists evidence to the contrary and is not shared by a particular sub-culture

14 Delusional Thinking WhoWhatWhenWhereHow

15 “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.” “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.”

16 Paranoia Paranoia = suspiciousness and mistrust that occur out of proportion to reality

17 Paranoia WhoWhatWhenWhereHow

18 Paranoia “Why do sounds at night make me jump? Why do I notice this?”

19 Disorganized Language Disorganization = speech or writing that does not follow a linear or logical pattern –Tangential, “loose associations”

20 Disorganized Thinking WhoWhatWhenWhereHow

21 “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?” “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?”

22 Clinically Useful Concepts Positive Sx Positive Sx Hallucinations, delusions, paranoia, disorganized communication Hallucinations, delusions, paranoia, disorganized communication Cognitive Sx Cognitive Sx Poor attention and concentration, memory problems, executive impairment Poor attention and concentration, memory problems, executive impairment Negative Sx Negative Sx Social withdrawal, affect flattening, avolition Social withdrawal, affect flattening, avolition

23 Clinically Useful Concepts: Positive Symptoms –Most specific for predicting psychosis Negative Symptoms –Mildly correlated with chronic prognosis Cognitive Symptoms –Strongly correlated with chronic prognosis

24 Diagnosis The basics: –Primary vs. Secondary –Other Symptoms –Symptom Time Course

25 Differential Dx of Psychosis Secondary Psychotic Disorders Substance induced psychotic disorder Psychosis secondary to a general medical condition DeliriumDementia Psychosis secondary to a mood disorder

26 Differential Diagnosis of Psychosis Mood Disorders Bipolar I disorder, manic episode Major depression with psychotic features

27 Differential Diagnosis of Psychosis Primary Psychotic Disorders Schizophrenia Schizoaffective disorder Brief psychotic disorder Delusional disorder

28 The Real Issue If you were to explain to a family member why someone has a diagnosis of a primary psychotic disorder, how would you do so?

29 Chronic Primary Psychosis Schizophrenia Schizoaffective Disorder

30 Schizophrenia: “definition” Schizophrenia is a chronic or recurrent disorder characterized by –Sustained periods of psychosis DSM = at least one month –Long-term functional deterioration DSM = at least six months

31 Schizophrenia: Diagnosis Two or more Criterion A Sx: –hallucinations –delusions –disorganized speech –disorganized/catatonic behavior –“negative symptoms” Flat affect, lack of motivation, social withdrawal

32 Psychotic Timelines Brief Psychotic Disorder –At least one Criterion A Sx –At least one day but less than one month of functional disturbance

33 Other “schizos” Schizophreniform –At least one Criterion A Sx –At least one month, but less than six months of functional deterioration

34 Other psychotic syndromes Delusional Disorder –At least one month –“Non-bizarre” –No other psychotic Sx –Impairment related specifically to delusion

35 Differential Diagnosis Psychotic Symptom Time Course Ruled out secondary causes Primary Psychosis Chronic (>1 mo) Schizoaffective Disorder Schizophrenia Delusional Disorder Psychosis NOS Brief (<1 mo) Brief Psychotic Disorder Psychosis NOS

36 DiagnosisSpecifiers Chronic Primary Psychosis Criterion A Sx and 6 mo dysfunction? Simultaneously meet criteria for mood disordes? Schzioaffective Disorder Schizophrenia Prominent Delusions? Delusional Disorder Psychosis NOS yes no yes

37 Diagnosis Brief Primary Psychosis Between 1 day and 1 mo Sx with full recovery Brief Psychotic Disorder Psychosis NOS yes no

38 Program Director: Rachel Loewy, PhD Scientific Director: Sophia Vinogradov, MD Medical Director: Demian Rose, MD, PhD PART


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