1. Assessment and Differential Diagnosis of Abnormal Experience
Illuminating Psychosis Demian Rose, MD, PhD, U.C. San Francisco Prodrome Assessment Research and Treatment (PART) Program
Assessment and Differential Diagnosis of Abnormal Experience

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

3. Chronic Psychosis
Often develops slowly, during adolescence and young adulthood
Early on, shares many Sx with other psychiatric disorders
Eventually leads to significant morbidity and mortality
As everyone here understands, the challenges we face

4. Chronic Psychosis Begins slowly Emerges non-specifically
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
Laboratories and imaging are often only minimally helpful
Clinical Interview is Important!

6. Psychosis is not:
One thing
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 7

8. Clinical Challenge Balancing two factors:
Subjective patient experience
Specificity of symptom presentation
I think we’ve focused too much on the latter, maybe because we see psychosis as this cliff or separate process
But 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

9. Psychosis Hallucinations Delusions or Paranoia Disorganization
Catatonia
Operatively defined as a problem with reality testing, although that’s a pretty broad category.

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

11. Hallucinations
Who
What
When
Where
How

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.”

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
Who
What
When
Where
How

15. Delusional 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.”

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

17. Paranoia
Who
What
When
Where
How

18. “Why do sounds at night make me jump? Why do I notice this?”
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
Who
What
When
Where
How

21. Disorganized 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?”

22. Clinically Useful Concepts
Positive Sx
Hallucinations, delusions, paranoia, disorganized communication
Cognitive Sx
Poor attention and concentration, memory problems, executive impairment
Negative Sx
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
Positive 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):9-17
We 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?

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
Delirium
Dementia
Psychosis secondary to a mood disorder
Secondary 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.

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

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

28. The Real Issue
Forgetting 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?

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
The 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.

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
When 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

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

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

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

38. 415-476-PART Program Director: Rachel Loewy, PhD
Scientific Director: Sophia Vinogradov, MD
Medical Director: Demian Rose, MD, PhD
PART